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S Alm Jr OA U I N LOCAL, �-iF�A r.Tl�O I S TR I CT <br /> UNDERGROUND TANK DISPOSITION TRA((ING 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 permit with number noted below iresponsible for <br /> e su ing that this form Ss completed and returned <br /> FACILITY NAME: Mnorman' s Water Cyctemc <br /> FACILITY ADDRESS: 2120 Wilcox Rd. Stockton, Ca. 95205 <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank remov$l contractor: <br /> `rank Removal Contractor: Moorman'5_ Water ('Systems <br /> Address: 2120 Wilcox Rd. Zip: 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: Cr-iso Tank Testing _(maybe) <br /> Address: 'Lip: <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 /> 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 /> AMHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFF1X PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDL1,GROVND TANK PROQ:AM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />