REMOVAL_1989 - Laserfiche WebLink

Home Browse Search

SAN .70�+aS*�,IN LOCAL HFnr.'I'Il•�LjIS•I.122C'I` UNDERGROUND TANK DISPOSITION TRACKING RECORD xxxtxtxttxtttxttxttttxxttxxxxxtxxxxxxxxxxxxxtxxxxxxxtxxxxxxxtxxxxxtxxxxxtxxxxtxttttxxtxxxtx 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 mi wi h n +��r no as b low i responsible for ensuring that this form is comr)IPted and returned FACILITY NAME: eft L IAC FACILITY ADDRESS: TANK ID #39- ****xxxxtxtttxtxxxxxxxtxxxxxtxtxxxxxxxttxxxxtxxtttxtxx*xxxxx**xxt*x**x*x*x**x**xxxxxxxxxxxx SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor:—S Address: Zip: Phone#: Telephone: ( d9 Date Tank Removed *******x**********x*t*******x**txxxxxtxtxxxtxxxxxxtxxtxtxx****tx**tx***x*xx*x**txxxxttxxtxx SECTION 3 -To be filled out by contractor "decontaminating tank": /� � ! Tank Decontamination" Co tractor• C%t k a 2l vn'Cjelj V Address: Zip: Phone#: 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 ttxxxtxxtxtxtxxetxtxxxxxxxxxxxxtxtxxxxxttxxtxxxtxxxxxx*x*x**xx*x**xxxx*x*xx****xxxxxxxxxxxx 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: Phone#: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE xx*x*xxtxxxtxxtxxx**xxttxtxxtttxxxxxxxxxttttxtxxxxxxxtxxxx**x*******xxx*x*x***xxxxxxxxxxxxx EH 23 049 12/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PR ER POSTAGE. SAN JOAOUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202