Laserfiche WebLink
UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> kttttt**t****x**t*t****x***R*R*xtRx*tRt*RtRttttxttttxt*RRxtRRtR*tt*tx****x*********tRttx* <br /> .SEC'T'ION 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 cermit with ,m&r noted be W is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: fel (J RI 1 F R a I C <br /> FACILITY ADDRESS: I cl (., ( )/\-I w� i <br /> TANK ID <br /> *tx**x*******x**xtxt***tt*xt**x*t*xt*tR**xttR ttx***t* xR*** kx*RtttRRfit***xtx***t*t*x*tt <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ �N F) Lt h A L L Cc) <br /> Address: — ?� 5 LA L <br /> v=a�l _� Zip: <br /> Phone#: <br /> Telephone: Date Tank Removed: <br /> t*t**t**xtRt**t*R**R****xfit****tfifixkx***fififi*fi*tt**fi*fifitxfiR*******t**fit**fi*fifi****Rfit**tR**** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Zip: <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 /> x*fits*x*x*x***ttxx*xtxtx*t*txxttx*xxxxRSIGNATURE <br /> xAND <br /> x*xTITLE <br /> xxx***xx**xx*xtfitxxtxkRtxxxtxxRt**** <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 <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> tx*x*t*x*xxx*xxtx*xRttxtt*t*x**RAUTHORIZED <br /> **xtGNx*x�R�*tANDxtxxTLx*xt**t*xt*t***xx**x*xR**tR*xxxx <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />