Laserfiche WebLink
SAN JOAQU2N LOCAL H��ar.TH D.1S'I'E22CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xx*zxxzxxX**Xxx**xxzz*X*****x*xx**xz*X***xz*xzzxXz**xz*x**x*zx**x**xxz**x*xz*Xzx**z**X***z* <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 form is completed and returned. <br /> FACILITY NAME: t i <br /> FACILITY ADDRESS: 20Li :5 Al AL��iuj tj-OrAn-c A/ e--4 <br /> TANK ID #39- 1 J - <br /> x****x*******zxxzx*z*********** **z*****Xzzz*x*z**xxzxxzzzxx*x***xzz*x****zxzxxzzxz*xz**x*z <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: FJ0Af a <br /> Address: pe. [? r C 9 L c crfrrrni -,I/ Zip: Z2 <br /> Phone#: VC- .1 0 o v <br /> Telephone: ( ) Date Tank Removed: <br /> zx*zzx*z*xzXz**Xzx*x*zzz**z***zx*Xxz*xxzxxzzx*z*z**zx**z**xxz*x*x*zzz**zz*zz*X*z**xx**z**** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 1-�,(/C Cn f 6 APi /.- <br /> Address: ACX VC ;1L S7-ce A/ C,4 Zip: 37,?O % <br /> Phone#: y/ .3 -2 o c o <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 /> X*X**XX****X****X*****************x**X************************X**x****z***x**XX**X**xX****x <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: Zip: <br /> Monet: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *zx*zXxz***zXx**Xxzzz**zzxxzzz*z****X**x*x******x*xx**x**x**X*****xxx*x*x*****Xxzxx*XxX**xx <br /> E!! 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. E3OX 2009 <br /> STOCKTON, CA 95202 <br />