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SAN JOAQUI N LOCAL t-rt~AT•TH DI S'ITZI CT <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 responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: East Bay Municipaly Utility District <br /> FACILITY ADDRESS: West Main Street Stockton, CA <br /> TANK ID 139- I - <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 $ox 76 San Francico, ZW 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 /tyDRO - GyE/Gt SBRVICes <br /> Address: f/UrVTeA r ;EV'//VT- :-5'h1ZP,4W1V) <.fAl Zip: / 2 <br /> Phone#: W4--O'22 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 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 />