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SAN aOAQUI N LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 reseonsible 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 rD 139- 11001 — C3 rr Il n <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:Hunters Point Shipyard, Bldg. 418 Box 76 San Francisco�Zi�A 94124 <br /> Phone#: 415 8 2- 81 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approvo <br /> 1 )nner as may be regulated by Department of Health Services. <br /> /�/ L:4-�1 , AA E� <br /> SIGJATURE 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: u. yFc�,� PT . S 1 Zip: C/( a <br /> s F-A, , f2�r_61,tCi,5Cn) ('^A Phone#: -)2z .2 dJ <br /> Da>;e`tank eceived: - <br /> AUTHORIZED SICUATURE AND TITLE <br /> EII 23 049 12/88 <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 />