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SAN JOAceIN Lo(-_P . i--I Friar •TFWI sa-a:i CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxx:xxxzxzzzxzzzzxxxxzxxxxxxzxxxxxzxzxxxzzxxzxzxxxxxxxxxxxxzxxxxzz <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 witb number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: Ar ( ( 1 Y ctI <br /> FACILITY ADDRESS: ���� `; i� � i' C_- 1y <br /> n .. <br /> TANK ID #39- .� ��>�C'1 <br /> zxzzxxzxzxxxxxxxxzzxzzzxxxxzzzxxxxzzzzxxxxxzzxzzxzxzzzzxzzzzzxxxzxxxzxxzxxzzzxzxxxxxtxxtxz*1' I� <br /> SECTION - 2 - To be filled out by tank removal contractor: b� <br /> /'.� <br /> JA N2 3 '�sa <br /> Ta.% Removall Cont;: ctolr. �' <br /> g <br /> Address: Zip: ��EwRVircr,yU. l{ <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> xxxxzxxxxxxxxxxzxxxxzxxzzxxxxxxxxxxxxxzzzxzzxzzxzzxzzzzxxxxxxxxxzxxxzxzzxxxxxzzzzzxxxxxxxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ksc)p Jilt <br /> Address: 255 P4frr, P!, CieA menti r 00 . Zi4• !2�/ , 0 / <br /> _Phone# 3 <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 /> zzzzzxzxzzzzzzzzzzxxzxzxzxxzzzxxxzzxzzzzxxzxxzxxxxxzxzzzxzzzxxxxxxxxxxxxxxxxxzzxzxxzxxxzzxz <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 �3f/lT OV L <br /> Address: Zip: <br /> Phone#: <br /> Date Tank R / 0 ` <br /> A IZED SIGNATURE AND TITLE <br /> xzxxzzzzzzzzzzzzzxzxxxxxzxxxxxz4t xzzzxxxxxzxzxxxzzzzxzxxzxzzzzzxxxxxxxxxxxxxxxxxxzxxxxxzxz <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTACZ. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. DOX 2009 <br /> STOCKTON, CA 95202 <br />