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Y <br /> SAN J c]AQLJI N LOCAL *4MA3L-TH DIS 7 R I C"1` <br /> WDFRGROUND TANK DISPOSITION TRAOCING RECORD <br /> a:*:ssssssssssst*ssssssssssr�ssssstsssssssssssssssss�ss:ssss�e�e#:re�e*s:*e:sst*esssss*s*ss****se <br /> SDCTION 1 - The San Jo$quin 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 akxeptanee of the tank by disposal or <br /> recycling facility. <br /> Shc bolder -of the Rermit with number noted LM12X 1s_rrsggnsib1e LQL- <br /> Ansuri that L form is ;2M21eted�and�returned, <br /> FACILITY HKM: Bast Say Municipaly Utility District <br /> F=LITX AMMS: Best !lain Street Stockton, CA <br /> TANK '-D 939- j I t0j_- <br /> ION - 2 - To be f i l led out by tank removal contractor: <br /> Tank RejwVal Contractor: Cottle Engineering <br /> Address: P.O. Box 163 Antioch, CA Zip: 94509 <br /> Phone#• <br /> Telephone: ( 415 ) 754-9935 Date Tank Removed: <br /> ssssssssssssssarsssstwtsstss*,r�*ss:ss**sstrsssss,es:t:**:r*ss**s:sass*ss*�tset*s*ss**s*ss*ssssss <br /> SWTICN 3 -Ta be filled out by contractor "decontaminating tank": <br /> TIODeeontamination" Contractor: Hydro-Chem Services <br /> Address: Hunters Point Shipyard, Bldg. 418 Xox 76 San Francico, M: 94124 <br /> Phone#: 41 822-1181 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> T <br /> ted in an app manner as away be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> tsssssssssst*sstssss:rs:tsssssssss:esssssssirssss,rssxssxsirsss*s**tissssss�ts***suss*stststsssssr <br /> BION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility ac[xpting tank. <br /> Facility YAM d'tQ6a-C} ei4 :929=dF T <br /> Address: ,ly . 145 AVVW7- ��Y/��jA�� S�Q�F, L/s"C� Zip• 27 <br /> .� �4! - <br /> ,. Phone#: <br /> Des Tank ived: - <br /> a2 <br /> ALTT1i AI ZED S I GNAT URE AND TITLE <br /> *ssssssssssfrlr�sss�*:rs�t�ts:ts*ss*sstss:tssssts**itsat:r*sts�tsss*ts*ss*tt*f�rsstssssss*sssttss*mss <br /> B!! 23 049 11/88 <br /> W <br /> INSTRUCTIONS: FOLD IN HALF AND STAPLE. AF`F`IX PRopER POSTAGE. <br /> 8A4 JOAQUIN LOUT HEALTH DISTRICT <br /> ATTN., UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 3009 <br /> STOCKTON, CA 95202 <br />