Laserfiche WebLink
. �►•�, 1031 Wz-u 1W CAP <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 hg1dgr of thet w Ig resUgn-sible for <br />ensuring that this form it s completed awl returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39- 11 - — e <br />SECTION - 2 - To be f i l led ccout <br />----by tank removal contractor: <br />Tank Removal Contractor: '�'�® <br />J <br />Address: AFIezZip: <br />Phone# : <br />Telephone: ),�� `'l`�r� Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: eQ- <br />Address: <br />.00 <br />Zip: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may gk_fated by Department of Health Services. <br />QJA'I�1KL<° 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 7.s' ��-��� �...�%.._... <br />Address: a !7X1--- �O <br />Zip <br />Phone 1: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 099 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. FFIX PROPER POSTAGE. <br />SAN JOAQUIN EDM HEALTH DISTRICT <br />i rffia UNDERGROUND TANPROGRAM <br />P. BOX 2009 <br />ST=TON, CA 95202 <br />