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S�,.N .7rOAQU=N Z...00,.Ata �..A.LTH D=S TR 2 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD 0 <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. M)e holder of the permit with nUmber,noted below 1s_res24nsible for <br /> gourins that this form is completed and rgtUKnt& , <br /> FACILITY NAME: .� c� <br /> FACILITY ADDRESS: ,,4 _�... <br /> TANK ID 139- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal. Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: ///,7 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> .nk Decontamination" Contractor: <br /> Address: o` r, / � Zip: <br /> Phone l: P?V <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 /> IGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility acceting tank. <br /> �-� V . <br /> Facility Name_ <br /> Address: �� J � • Zip: <br /> Phone#:�lVr yc <br /> Date Tank Received: —\ d <br /> AUMORIZED SIGNATURE AND TITLE <br /> S![ 23 019 12/88 • <br /> AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROD M <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />