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SAN a0AQLJIIN Loc A- HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *XXXX*XXX*X***XXXXXXXXXXXXXXXX***XX*XX*XXXXXXXX****XXXXXX*XXXXXXXXX*XX**XXXXXXXXXXX****XXX* <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 permit with number noted below is responsible for <br /> ensuring that this formiscompleted and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: LCI L <br /> TANK ID q39- �i2&0 70�) <br /> XXXXXXXXXXXXXXXXXX*XXXX****XX**XX**XXX*XXX *i1 ****Xik*X**X**XX XXXXXXXXX*X**XX***X****XX*XX** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: � u h� C Ae-rti -nY Aa C,A ����� Zi <br /> Phone#: cf31a�L <br /> Telephone: ( �' 1 )_ n ) �l - ? l Date Tank Removed: <br /> ************X************X**X***X***X***********X**************X**XXXXXXXX*XXXXXXXXXXXXXXXX <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ��Ancl t L" Pr t'' : �- 1_ 1 <br /> Address: 1 \1<<v �� �� .�( v����� _� {•� Zi <br /> rC 7 <br /> Phone-i: Z, <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 /> SIGNATURE AND TITLE <br /> ***XXXXXXX*****XX*X**X*XXXXX*XXXX****XXXXX*XXX***XXX**XXXXXX*XXX***XXX*XXX***XXX**X*XXX*X*X <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name L2 i <br /> Address:1 & L(1 <br /> Zip: C'' ` � <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *XXX*XXXXX*XX*XXXXXX**XXXX*XXX**XXXX*XXXXXXX*XXX*XX*XXXX*X*XXXX*XXX**XXXXXX*XXXXXXXXXXXXXXX <br /> Ell 23 049 12/88 <br /> MAILING 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 />