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n(Yv <br /> SAN JOAQUI N LOCAL, HEAT•TH DISTRICT �V <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> **w*******w*wwww**w***w*x*ww****w*xw****ww**wwxXXwwwwwwww**wwwwww*xwwww*wwwwwww*wwwww*wwwXw <br /> SECTION 1 - The San Joaquin Local Health Districts 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 nimbler ensuring that this form is completed and returned noted bel w IS *esoorsi�for <br /> FACILITY NAME: <br /> FACILITY ADDRESS: D -7 1 Lo TP <br /> 7G- <br /> TANK ID #39- --? 3-;4� - <br /> ***xww*Xxw***xw**X*xx********* w*w***wX**x****XwXX*Xww****x*****www**wwXX**xwwxww**** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> ! l ' <br /> Address: iii; , l <br /> R y 3f�/C 7 h b nc d1Zip: �7 <br /> Telephone: <br /> ***X*x**X*wxwwwx*w*w**wx***w************wDate <br /> *wX**Tank <br /> ***wXw�wwwwx***wArt*www**ww..... xwwwx*ww <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ! <br /> Address: Y"� f - C7 S <br /> Zip: <br /> Phone#: <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 /> *Xx*xXxXXXXX******wX*x**XXX***xxXwXx***�*'xTURx*�NDxxXTL**x*w*xw*x**Xwww*xxwww*xxX*xwxw*wwxwx <br /> SECTION 9 - To be filled out and signed by an authorized <br /> storage, or disposal f represneta <br /> Po facility accepting tank. trve of the treatment <br /> Facility Name G p j <br /> Address: :/ , <br /> Zip: C-) <br /> Date Tank Received: Phone#: t32 <br /> AUTHORIZE <br /> ***xx*w***Xww**ww**xwww*****xwx * ***D****2***T******D**X****x*w*XXww**XxwwwwwXwwwx*xwwwX*w <br /> Ell 13 099 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE, AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Arm: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />