Laserfiche WebLink
SAN aOAQUIN I OCCAL HH' I -FH DI STRI C'I' <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:—AP-c-6) 'Far i \,k 41 (o I D b <br /> FACILITY ADDRESS: Z5�1�I5 S. Po.�k er'son tSS 2A <br /> TANK ID #39- <br /> SECTION <br /> 39-SECTION - 2 - To be filled out by tank removal contractor: <br /> 'rank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date 'rank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <br /> Phone#: <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 /> ******•k********k***kic**k*k****�Ikii***k*****k******k******kit*:1*****k***ick******icic*ick****it*ir*tc <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 <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *******�kkk*ic***kikk**iric>tic**icyt*ic*****k*�r�kkic*kkkkt•****k****�icickkk*ir**prick*� � k� kk*k <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT1990 <br /> ATTN: UNDERGROUND TANK PROGRAM ►"NVIRONMENTAL HEALTF <br /> P. 0. BOX 2009 PERMIT/SERVICES <br /> STOCKTON, CA 95202 <br />