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SAN J OAQV I N LOCAL HF�AI.�TH D I S T 'IC <br /> • UNDERGROUND TAMC 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 /> 0 <br /> recycling facility. <br /> FACILITY NAi4E: East Bay Municipal Utility District <br /> FACILITY ADW S: West Main Street Stockton, CA <br /> TANK ID 139- _ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Cottle Engineering <br /> Address: P.O. Box 163 Antioch, CA Zip; 44509 <br /> Phanel: <br /> Telephone: ( 415) 754-9935 pate Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Sk Decontamination" Contractor: _ Hydro-Chem Services <br /> Address:Hunters Point Shipyard, Bldg. 418 Box 76 San Franciscogi 94124 <br /> Phone M : 41 - 1 <br /> AutN representative of contractor certifies by signing below that the tank has been <br /> de ta <br /> onmi ted in an a ov } neer as may be regulated by Department of Health Services. <br /> r• / frAA kNo—ov <br /> SIGNATURE AND TITLE <br /> X <br /> SEM_ ION 4 - To be filled out and signed by an authorized represnetative cf the treatment, <br /> 1 storage, or disposal facility accepting tank. <br /> Facility Name jV Ov-c:> C_j_t Fn!\ Srz.J% c9_L"Z_ "_Ir, <br /> Address: t, cf !a Zip: c• <br /> r . <br /> Da nk ce ived: <br /> (W)a------ - <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 23 049 12186 <br /> LING I NSZRUCTI ONS: FOLD IN HALF AND STAPLE:. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEhLTH DISTRICT <br /> ATTN: UNDID G ROUND TANK PROCI M <br /> P. 0. WX 2009 <br /> STOCKTCN, CA 95102 <br />