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' ' SAN J02�Q�N LOCAL. HE ALTH •2 STR 2 CT UNDERGROUND TANK DISPOSITION TRACKING RECORD xxtttt****xzt****z*ttzz****txxrz**x*xxx**xxxxxxxxxxxx*xxxxxxxxxxxtx**r*x**tttzzt*ttr**tr*x* 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. The holder of the permit with number noted below is responsible for rns_u_rino that this fnrm is completed a ot.:rn a FACILITY NAME:_ �09 &In/J-737 �d FACILITY ADDRESS: (90 (j)&w TANK ID 139- �� .7 _ 3 ***********t*x*x*xx****x*txx***x*x*rr**x*xtx**x***x*x**xt****xtx****tt********r************ SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor: WESTERNMETER' SERME Address: Stockton, CA 85205 848 61 4 Zip: Phone#: Telephone: (2L�_)_ Date Tank Removed:_ SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: WESTERN METER SERVICE Address: 8tookton, CA 85205 Zip: Phone#: Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved ma as may be regulated by Department of Health Services. SIGNATURE AND TITLE **r**x*x*xx*x*z***x*x*xx*x**x**xx*z*x*r**zr**r**xx*xx**x*rxxxx**********x**r*******x**x**xx SECTION 9 - 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:—.."a **********************t*******AUTHORIZED SIGNATURE AND TITLE IGNATUEANDTLE EH 23 019 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