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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SECTION 1 The San Joaquin Local Health District's Tracking Sheet <br />will accompany each tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to San Joaquin Local Health <br />District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted above <br />is responsible for ensuring that this form is completed and returned. <br />FACILITY NAM: �War-Y ='jsj.S L(L Ht!Lf <br />FACILITY ADDRESS: 3-7,.)-S- —fiek-Y W, T(WY-TANK ID #39- 141-7-0 <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Phone # <br />Zip_ <br />Date Tank Removed <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank "Decontamination" Contractor <br />Address Phone# <br />Zip <br />Authorized representative of contractor certifies by signing <br />below that the tank has been decontaminated in an approved manner <br />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 <br />representative of the treatment, storage, or disposal facility <br />accepting tank. <br />Facility Name <br />Address Phone# <br />Zip_ <br />Date Tank Received <br />AUTHORIZED SIGNATURE AND TITLE <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P.O. BOX 2009, 5ToeKToN/, CA 95201 <br />