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VED <br /> SAN .70AQUI N LOCAL, HEALTH 01 am <br /> OCT 2 6 1989 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD ENVIRONMENTAL HEALTH <br /> *******x*xxx********�*****W******W**W***W*****W***W**WW***************iF FcX•WIt NMd�FaF�Mil�*SrYr1?fi*** <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 belov is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: East Bay Municipal Utility District <br /> FACILITY ADDRESS: West Main Street Stockton, CA <br /> TANK ID 139- _- <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 /> Phone#: <br /> Telephone: ( 415 754-9935 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Hydro-Chem Services <br /> Address:gunters Point Shipyard, Bldg. 418 Box 76 San Francisco Zi 94124 <br /> Phone#: ` 41 8 - 81 <br /> Au t representative of contractor certifies by signing below that the tank has been <br /> de onntamihated in an ap ov 7,nner as may be regulated by Department of Health Services. <br /> AA E)je- <br /> SIGNATURE AND TITLE <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 <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Elf 23 049 12188 <br /> MAILING 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 />