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. SAN JOAC�UI N LOCAL HEALTH DISTRICT <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: Qy-G6) Earl # (o lDO <br /> FACILITY ADDRESS:_ PcLkA erson �PaSS Q. <br /> TANK ID #39- 17ai - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:-11 <br /> Address: <br /> Zip: <br /> Phone#: it `i2 J CGl <br /> Telephone: ( ) Date Tank 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 thkit the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <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_I/ /� S�/� �(Jl cz." f!l>G <br /> Address: T-71 <br /> Zip: <br /> Phone#. <br /> Date Tank Received: �- (,�'l,�C �L:�J��//U�97Lyr <br /> AWHORIZED SIGNATURE AND TITLE R <br /> E11 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT MAS 11 1990 <br /> ATTN: UNDERGROUND TANK PROGRAM r-WRONMENTAL HEAU <br /> P. 0. BOX 2009 PERMIT/SERVICES <br /> STOCKTON, CA 95202 <br />