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. SAN J©��UIN LOGi�L HEALTH i7I S'I'RiCT <br />UNMGROUND TANK DISPOSITION TRACKING RECORD <br />**._n**each*tank. <br />h]GTION 1 <br />The San Jo identi ELic�atioanambergt iThegTracking Track Tracking Sheet t is i to be rll eturned to San <br />ffixed with its site disposal or <br />oaquin Local Health District within 30 days of acceptance of the tank by <br />ecycling facility. <br />fox <br />AGILITY NAM <br />ACILITY ADDRESS: <br />'ANK ID 139-******************#******* *****s********** <br />ECCION - 2 - To be filled out by tank removal contractor: <br />I enk Removal contractor:,z <br />I ddress: <br />'elephone: ( ) Date Tank Removed: <br />WrION 3 -To be filled out by contractor "decontaminating tank": <br />1p: �+ 0 <br />anl- Decontamination" contractor: <br />ddr. -i - Phonel. <br />/Y1U <br />,uthorized representative of contractor certifies by signing belowwtthatof e t th Seryhas ices. <br />en <br />!econtaminated in an approved manner as may be regulated by Depa <br />SIGNATURE AND TITLE <br />;pCIIOM 4 - To be filled oi4t and signed by an authorized xepresnetative of the treatment, <br />itorage, or disposal facility accepting tank. <br />'ecility Name <br />Zips <br />wAdresss Phone#: --- <br />)ate Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />H 23 049 13/80 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />sAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />