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V`. H MILT.,-r H D= STRICT <br /> SAN .70A� "2 N LOCAL., <br /> V �,�+ <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: C-.t'.T of Tracy rest_...- on 12 <br /> � ) <br /> FACILITY ADDRESS: 301 E. Gran L—ne Rd Tracy . C' 95 3 17 0 <br /> TANK ID 139-- <br /> SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: t 2' <br /> Address: t i.�,9 cf - Z ip: 0S 3 <br /> U . Phone#:�2cw-- <br /> Telephone: <br /> -Telephone: Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �' c <br /> Address: -Q i �-1 t-� It�i-�1� "i�� C _Zip: q 3 <br /> Phone#: - 26: -0 <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 /> SECTION 4 - 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. AI'FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOQKTON, CA 95202 <br /> I <br />