Laserfiche WebLink
Y <br /> RECEIVE : <br /> S <br /> AN .70AQUIN LOCAL >f- M2ka TH DI STR:CCM 6 1989 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD ENVIRONMENTAL HEALTH <br /> PERMITxxtttxlxttttt*t#*txxt*x*xtt*t**xttxxtt*x*x**wxxxxxx**txx**xtxxxtxxt*txxt*xxxtwxx/SER ICES t <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 uumber not Ll w is responsible f <br /> or <br /> ensuring that thio fnrm is COAL letE'a _n„ T ��r nr.�. <br /> FACILITY NAME: East Bay Municipaly Utility District <br /> FACILITY ADDRESS: West Main Street Stockton, CA <br /> TAW(ID 139-____ Ll <br /> xxxwwwxwtxxxt*t*xtwxxttxtttxxtxxxtxtwxtttt�tittxttxxxxtxxtxxxxxxxxxttxxxxxxxtxxtxxxxxxxxxwxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Cottle Engineering <br /> Address: P.O. Box 163 Antioch, CA Zip: 94509 <br /> Phoney: <br /> Telephone: ( 415 ) 754-9935 Date Tank Removed: <br /> xxxxxxttxtwxxxtxtxxxtxxrxttxxtxtxxxwxtxtxxxxxxxxtxtxxtxxxxxt*t*****xx*xx****x**xxxxxxxxxxxt <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Hydro-Chem Services <br /> Address: Bunters Point Shipyard, Bldg. 418 $ox 76 San Francico, <br /> 94124 <br /> Phoney: 417-8-271=8 1 <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 /> txtwtwxwwtxxtttxtttttxxtxtxxxtxxxxxxtxxGNtxTURxxxNDxxxTLExtxx:rxxxxxxxxxxxxxttxtxxttxxxxxtxxxt <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 Named C� _.I.i �fpi/ACES <br /> Address: I-le -egxs zip: --?4 / 7-4 <br /> Phone#: <br /> Oa Tank ived: <br /> rxxtxwxwtttxxwxxtxxxxtxx*wxx**xAUTHORIZED SIGNATURE <br /> AND TITLE <br /> *xxtttxwxtxtttxxtxxxxxxxtxxxxxt <br /> 311 13 049 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX pROpER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKWN, CA 95202 <br />