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SAN .7OAQ�N LOCAL HEALTH `I Sial 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 r)ermit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: (� �2�1Y I< P � J�Y{ e i I( I iLCt <br /> FACILITY ADDRESS <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: JAN o ,9�� <br /> Tank Removal Contractor: +«--- <br /> PERMI(%SE�VICFc LTH <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> ****xx*******x****x**k******x***x***x**************k***x*x*x***x***xx**xx*****xx***x**x***x <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: } F -icksoH ZL <br /> Address: � S� 89rr flw (� Zip: 161801 <br /> // Phone#: <br /> Authorized r �e$entative of contractor certifies by signing below that the tank has been <br /> decontamina d ,in an appy ved ex as may be regulated by Department of Health Services. <br /> 1 e tJG' o 'er r rR r ,-e Oy <br /> SIGNATURE AND TITLE <br /> ****xx****x***xx***x******xx** *kxx*****kxx**kx***x*xxx****x**xx**kx***x**kxx******xx*x*x <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 ��t^i C ( gni^ -4,oC <br /> Address: 5 _ Q rr r1,7 0M CY ( ' Q. Zip: c/ o <br /> Phone#: C�iIS) 13y 139'3 <br /> Date Tank Re <br /> SU PT(.jISor <br /> Al lORIZED SIGNATURE AND TITLE <br /> EH 23 049 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 />