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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number, <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or ` <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: 12_ IMIHF Z '!5?eOV <br /> FACILITY ADDRESS: �J2�J',1�liL IS TANK ID #39-/ <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone # <br /> Zip <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zin <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> 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 <br /> representative of the treatment, storage„ or disposal facility <br /> accepting tank. <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tank Received 4 <br /> AUTHORIZED SIGNATURE AND TITLE <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 95201 <br />