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SAN JOAQLJIN LOCAL I mALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *x**A#ttxtAA**Att*ttA*A*ttx*#t*t*tx*xx*t*xt*txxxx**ttx*x**xxx*x*xtxtt*tt***xttxt*tttxxt*xtx <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 is responsible for <br /> gnsuring that this form is completed and returned. <br /> FACILITY NAME: East Bay Municipaly Utility District <br /> FACILITY ADDRESS: West Main Street Stockton, CA f,. . <br /> TANK ID 139- � (0/I NoV 2 <br /> xxxxxtxxxxxxxxxtxxAxttxtxttxxxxxxttxxxxtxtxxAtxxxtxtxxxtttxxxxt�lt��'�$t�4�trfitRatfittA#txxxtttt*xtx <br /> SECTION - 2 - To be filled out by tank removal contractor: rrh�T <br /> H <br /> Tank Removal Contractor: Cottle Engineering `o <br /> Address: P.O. Box 163 Antioch, CA Zip: 94509 <br /> Phone#: <br /> Telephone: ( 415 ) 754-9935 Date Tank Removed: <br /> x*xtAxxxxxxt*txxxtx*xx*t*t*****x*****xx**x*xx*ttx*A*tx**xxxxx*x*xx****txxxt*xxxxt**x*xxxxt* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Hydro-Chem Services <br /> Address: Hunters Point Shipyard, Bldg. 418 $ox 76 San Francico, Z": 94124 <br /> Phone#: ( 415 822-1181 <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 /> txtAxxxxtxxxxxxttA*t*xxxxAx*xttxx*xtt**t*txxxxxxxxxxt*txttxxttt**xtxtxttxtx***xxx*xxtxxttxt <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 ///';DACf/5W SEiRU/GE'S <br /> Address: 1f//st/T�.45 /'o/it/T Sh`��yA��Zf s�4�/FiPiOif/C/SCS zip: 4/ 29 <br /> Phone#: <br /> Da Tank ived: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *x*xtAAt A*xxtt xlFAAAx*A*x*Ax"xx*At#t**x**t*tt*CARR xltxxtxxxxtt*xxtAtxtxttt*ttttxt*t*xxxttxxtttt <br /> Elf 23 049 12/88 <br /> HAILING 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 /> STOCKTON, CA 95202 <br />