Laserfiche WebLink
„y .,. SAN .70AQ�N LOCAL HEALTH �ISTRICT + <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> s*sssxs*ssx**xx********zxxxx*zxxxxxx*xxxxxxxxxxxxxxxxxxxxxzxzxzxxzxzzxzzxxxxxxxzxxxxxxsssxx r' <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank i <br /> affixed with its site identification number. The Tracking Sheet is to be returned to San 2; <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> r- 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: <br /> FACILITY ADDRESS: HXL.)C7 ) C� <br /> TANK ID #39- L <br /> xxxsssxsx***x*****x*xxxxxzxzzxzxzzzzzzzxzzzzzzzzxzzzxzzxxzzxxzzzxxzzzxxzzzzzzzxxxzzxzzxxzzz <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: lCiT�(N GTcOz S�tVIGc . 9Nc <br /> Address: 2 ---v Cit In e4 zip: 9s zr�s <br /> Phone#: <br /> Telephone: (o1Z�Date Tank Removed: <br /> ssxsxxssssxxxxxxx xxxxxxxxxxxzxx*xxzxxxxxxxzxxxxxzxxxxxxzxxxxxxxzxxxzxxxzxxxxxxxxzzxxxxxxsx �- <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : ' <br /> s' <br /> Tank Decontamination" Contractor: WE�S7 ,=GI A) /�r�r oz �cZ2Vt��, // - <br /> p <br /> Address: 2.73 L I c PC—” J Z 1'0 c)<-mo Al . C/4- Zi <br /> Phone#: � Z� 6- <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 /> r <br /> SIGNATURE AND TITLE ` <br />'yxx**xx*s**x**xzx**xz**x***x*zxxxxxxzzzzzzxzzzzzzzzxzxzzzzzzzzxzzzzzzzxzzxzxxxzzzxxzxxxxxxxz } <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, '. <br />; storage, or disposal facility accepting <br /> tank. <br /> Facility Name 4; <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE7II <br /> xxxsxxxxxsxxxxxx:rxxxxxxxxxxxxxxxxzxzxxxzxxxxxzxxxzxzxxxxxxxzzxxzxxxxxzxxxxxzxxxxxxxxxxxxsxx <br /> EH 23 049 12/88 1 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. ;n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM rt; <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />