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• SAN 00*UIN LOCAL HE:2Lr •H DISrra1CT UNDERGROUND TANK DISPOSITION TRACKING RECORD x*xx*x*xxxx**xxxxx*****x**xxzWx**x*xxxx*x*zzxxxxxxx*zxxzxxxxxxx*x**xxx*xx********xx**xxxx** SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site Identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the permit with number noted below is responsible for ensuring that this form is completed and returned. q FACILITY NAME: �jj ii )`1 C t _ 'J K'i C FACILITY ADDRESS: TANK ID 039- xzx*x**x**xxx*x*x**W*x***xxxWx*****xx***x**x*xxxxx*********x**xxx**x*xx****x**xxxWxxx*xz**W SECTION - 2 - To be filled out by tank removal contractor.: Tank Removal Contractor: V\1 fn� l_T HR l . C.-r)I-A Si- Address: >L� l� C.1 � , t(>> 1 Zip: Phoned: Telephone: ( ) Date Tank Removed: *xx*x*x*z****xx*xxx*****x**x*x**xxxxx*x**xxx*x*xxx*xxxxx*xxx*xx*****xxxxx*x**xx****x**x*xxx SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Address: Zip: Phoned: Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE **xxx**xxW*xx**z****xxxx**xxxxx***x*xxx*zWxxxxxxxxx*z*z*xxxxxxx**xz**xx*xxx*z***xxxx*x**zx* SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Name Address: Zip: Phoned: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE ****x********xx******x*xx*****x*W*********Wx**********W*******xx*************x********xxx*x EH 23 099 12188 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202