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SAN JOAQLjIN LOCAL. HMAT•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RDODRD <br /> x*z*z***zx**z*x*zz***x**********z*z*****z***zz*x**x**z**x*z**z***x*****z******zzx*********z <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 holderof the permit with number noted below is responsible for <br /> ensuring that this form is completed and ret_U <br /> FACILITY NAME: East Bay Municipaly Utility District <br /> FACILITY ADDRESS West Main Street Stockton, CA <br /> OCT E111; D <br /> 2 6 1989 <br /> TANK ID #39- - -- � � # ** <br /> SECTION - 2 - To be filled out by tank removal contractor: PERM111/SERV CES <br /> Tank Removal Contractor: Cottle Engineering <br /> Address: <br /> P.O. Box 163 Antioch, CA Zip: 94509 <br /> Phone#: <br /> Telephone: ( 415 ) 754-9935 Date Tank Removed: <br /> x*z*x**z****z*z****z**zx*****x*****x******z**x**z**z****z********x***xz******x*zzx*****z**z <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, 20: 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 /> 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 /> ****zzzz**zxz***zzz*zzz**z*******zz***z*****x**********zzz****x***z****xzx******z*x*z*x***z <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 />