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SAN SOAQUIN LOCAL HF'a�r.TH 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 hold r of the De . I with numhPY <br /> e surin --ted low . s re t�otLible for <br /> g that this `ff9rm/ ils�compl��eyyted and return �1- <br /> FACILITY NAME: <br /> FACILITY ADDRESS: �� <br /> TANK ID 039- <br /> SECTION <br /> 39-SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor�l s %i ZD <br /> Address: Zip: <br /> Phone#: <br /> Telephone: Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: �� <_77 <br /> Phone k zip: <br /> TOS <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be gelated by Department of Health Services. <br /> IGNA E 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�E <br /> Address: Zip: Sda�v� <br /> Phone q: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. M.FIX PROPER LPO �AG>✓: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGVtAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />