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SAN .7� UIN LOCAr_ �-TF'Ar� DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />****x**x*************x*x*xxx***x*****xxxx****x*x**x*x***x**xxx***x*x*xxxx*x*******x****xx*x <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification number. The Tracking Sheet is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted below is responsib a for <br />ensuring that this form is completed and returned._ <br />FACILITY NAME: , / 1' <br />FACILITY ADDRESS: �y< .4 <S a,- n�a 1 ri 1989 <br />TANK ID #39-_-- <br />SECTION <br />39-- SECTION - 2 - To be filled out by 'tank removal contractor: PE's <br />Tank Removal Contractor: __ <br />Address: <br />ZiD: <br />Telephone: (ateDate Tank Removed: <br />*xxxxx******x**********x*******x***x*xx************x***x****x*********x****x*xx*xxxx***xx** <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />ip: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />Address: <br />Date Tank/Wo4ived: d/Io <br />*************** <br />El! 23 049 12/88 <br />14AILING INSTRUC <br />C�JTHORIZED SIGNATURE AND TITLE <br />FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATM: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />_Zip: <br />