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• 0 <br /> SAN aaAQUIIV LOCAL HFA.r.TH 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 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the Dermit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: Moorman' s Water Systems <br /> FACILITY ADDRESS: 2120 Wilcox Rd. Stockton, Ca. 95205 <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ Moorman' s Water Systems <br /> Address: 2120 Wilcox Rd. 95205 <br /> Phone#: <br /> Telephone: ( 209 ) 931-3210 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Crisp Tank Testing (maybe) <br /> Address: 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 /> SIGNATURE AND TITLE <br /> ******k******�k**��k*�***�'k�kit*ir��liral**ick**�'k*�Y*�1'�t*7t it Jr*�t**9cic9c'k*:l•�ticic'k**icic�lc*Ir�t**it�k7F 3c�Y9ci�*�ticicit�c*�Y*ir <br /> SECTION 9 - 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 /> *****�Y�k�k�kic*it**�k**9t**�k*9c*�Icic 4c**Ylr�lc�krY4r�t*5ta�9k�k�Y9c9raY*#7k*�k7k�k9c*�Y�k*�Icir�t�Y:k**�Ir*�Y�k�i�Ic�k*�k****�k�k*ar*�l�k**�k9kiic;k�r�t' <br /> E1( 23 049 12/88 <br /> 14AILING INSTRUCTIONS: FOLD IN HAI,F AND STAPLE. AFF1X PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL FEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />