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SAN .70A4Jk4 LOCAL. 141F-AA1.rrIWIST1:;1' ICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *W***#****Wx#***x**x*******x*xW***********xx*x****x*xx*xx**xxxW*W****x**W**xW**WWW*W*x*x**x <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 narmit with npnber noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: I Y l CA Y �c� 'f `�) �Y f C � �CA( <br /> FACILITY ADDRESS: ( �� �� LA 'f _C +' - 7�) �Z31 <br /> TANK ID 139- ���i - 00 <br /> SECTION - 2 - To be filled out by tank removal contractor: (1V'1 <br /> Tank Rvaoval Cori'"-actor: <br /> `AL HeALTH <br /> Address: Zip: <`VICES <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Er"C! -SOh <br /> Address: g5S r✓ Zip: gyE-d i <br /> Phone#: <br /> Authors r presentative of contractor certifies by signing below that the tank has been <br /> decon' ed in an appro manner as may be regulated by Department of Health Services. <br /> Jour <br /> SIGNATURE AND TITLE <br /> x************xx*WW******* **x*************W**W*x**x***x**********W*****WWW*W******x****** <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name ✓1r� /7 go V C <br /> Address: Zip: <br /> Phone#: <br /> Date Ta /eived: - <br /> ze <br /> GLi alZ - �U PvJiC or <br /> A ZED SIGNATURE AND TITLE <br /> *******Wx*W********************* ***********Wx****W***********WWWW*WW**x******x*x*WW*W***W <br /> EH 23 099 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 />