Laserfiche WebLink
' SAN .JCOAQLJIN LC- <br />C)AL HEALTH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 clays of acceptance of the tank by disposal or <br />recycling facility. The holder of the QPrmit with number noted bel9w is responsible for <br />e su that this form is complete¢ and returned. <br />FACILITY NAME: Trephouae Nursery <br />1 FACILITY ADDRESS: 8980 E, Hwy 12 / Victor, Ca 9-5253 -- - <br />o/_ 67C- 9,0 Q 3 - a,000q has <br />TANK ID 139- q� �Y3 0 - 61— © 0,X - 4e q4 S 0,y - -T-6 <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Herbst Engineering, Inc. _ <br />Address: <br />P.O. Box 22504 Sacramento, CA <br />Telephone: ( } Date Tank Removed: <br />SEyCTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: Herbst Engineering, Inc. <br />Zi516)422-26-72-8 95822 <br />Phone#: �9i6 - 6 8 <br />Address: P.O. box 22504 Sacramento, CA Zip: 95822 <br />Phone#:(916)422-2628_ <br />Authorized representative of contractor certifies by signing below that <br />decontaminated in an approved manner as may be regulated by Department <br />the tank has been <br />of Health Services. <br />SIGNATURE AND TITLLa' <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 Name <br />Address Zip <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOpCTON, CA 95202 <br />