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i <br />SAN J'O►AQXJI N LOCAL I- MAL.TH 01 SZ'E2I CT <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 oermit with number noted below is responsible—for <br />ensuring that this form i�rmpleted and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39 - <br />SECTION <br />39 -SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 4�FeZ 404�5 <br />Zip: <br />Telephone: �)-¢g— <br />rre!!O � pate Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: Address: Zip: <br />Zip: <br />-��1 Phone# : <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may <br />>-€fgyvrated by Department of Health Services. <br />1GNAjVR1s 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 75�'� <br />Address: <br />Zip • /,; co�� <br />Phone # : <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 019 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE.. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROC AM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />