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SAN a OAQ' -1-1 L OC.23,La I-IEAT.rrH = S TR 1 CT <br /> %P/ <br /> UNDERGROUND TANK DISPOSITION TRACKING RDCt6 <br /> :� i####t#####*########***###*,rx#xx**:�*xx**#xxx#**xx�tx***#***z#*****#********#***#*x/***t*x•#:** <br /> .SECTION Z - 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 permit„with-number noted below is responsible fQr <br /> ', -:ensuri that this form i completed and returned. <br /> FACILITY NAME: <br /> ° FACILITY ADDRESS: <br /> TANK ID #39- - a <br /> 7r##*######**#*#�C7k7k�t**#******il***7r�k#****Xyl'###�k***7l•*7kxx7C****�l*##**#7k**�k7k**#****##*###7t#x7k**** <br /> SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ <br /> Address: 2 oyn. l]: ' �� ;_AJC 1'S.��.eJ K' Z i p: =r7 r <br /> Phone#: <br /> Telephone: (,f,24 G__) �{' / Date Tank Removed:' <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> :. Address: _ �--�3r ✓�on C� �'%� f{ - t�'�4, zip: So'to <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been ' <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> i <br /> SIGNATURE AND TITLE <br /> F <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> .storage; or disposal facility accepting tank. <br /> t <br /> Facility Name <br /> Address: <br /> Zip: <br /> Phone#: } <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> .EN 23 049 12/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />