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SAN .7O2!jQUIN L,OCAT. HEAT•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 holder of the permit With number noted below 15 rear)onsible for <br /> C1_►a4drin that this form is comdleted and returned. <br /> FACILITY NAME: � i�-��� UKJl t=1 � <%1 ;,> ,'�� iE�r'l Y +`� I 1� <br /> FACILITY ADDRESS:�„�'1 <br /> TANK ID 039- = <br /> *x****************rt******* �'�`ik�t*ilr**5 <br /> SECTION - 2 - To be fill e out by tangy rem l 1/6'4iactor. r <br /> Tank Removal Contractor: �� J 4:�S'V'' -�ST , <br /> Address: ?5Jv Zip: <br /> Phone#: <br /> Telephone: G-)-O` ) `�� 3 � Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: jAC , <br /> Address: -S � ��fa1 �� ����1�7 _ Zip: <br /> Phone)! <br /> Authorized representative of contractor certifies by signing below Ukit 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 <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <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 />