REMOVAL_1989 - Laserfiche WebLink

Home Browse Search

UNDERGROUND 'TANK DISPOSITION TRACKING RECORD xxxxxxt�xxtxtt,r**rt*�r#****�*y�,�,xxx*t*x*xx**xxxs**sx*xxxxxxxxx*x**xxx************,�*�rx#*,r*xsxxx SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. 1bg holder of the permit with number noted below_15 resp ible for arm is completed,-And return_ FACILITY NAME; ap,�, FACILITY ADDRESS: .�i�C% /�%'/k—i iV --j TANK ID 139- f - xxxxxxxxxxxxxxxxxxxxxxxxxx�tx***"t***,rxx�r***t**,rxx�rx�r*xxxt***xxxxxx**xxx***�r*x*xxx�rx****x*xx* SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Address: Zip: Phone#: Telephone: ( ) Date Tank Removed: *xx**x*****x*x***xxxxx****xxx*xxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxx*xx*xx****xxx*xx*xx***xxxx SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Address: Zip: Phone#: Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE xxxxxx*xxxxxxx**xxx***xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx�,r********x*�rxrr*x*xx*x**x**rrxx*�r�r** SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Name Address: Zip: Phone#: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE *xxxxxxxxxxxxxxxxxxxxxxx,r*xxxx*xx�rxxxx*xxxxxxx*x*xxrrxx*xxxxxxxxxx*xxxxxxx*x*x�rxx***xx***xxx EH 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202