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i SAN 0 0AQUI N LOCAL HEALTH D I S TR I CT UNDERGROUND TANK DISPOSITION TRACKING RECORD ******x**XX***xXX**xx**xxX**xx****x*XXxX**xxXX**x****xxX**xx******xx*xx*x****xx**x****X*x** 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 FACILITY NAME: THE SERVICE STATION FACILITY ADDRESS: 1100 west Eleventh Street, Tracy; California 95376 TANK ID #39- - *******x*xX*X*X*xX*****X**xx****xx***xx***XX*xx*XXXXxxX**XxXXx*XX******X*XXx*XXxx*Xxx**XX** SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Address: Zip: Phone#: Telephone: ( ) Date Tank Removed: ***x*****x****X*******xX****X***x***xX**XX***x**************XxX*xxX***x*x****x***X********* SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: 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 ****X*RX*****xX*X**XXXXX***X**xxX*X*X*XXX*xXX***XXX*kxXXXX*X**XX***XX*x*X*X**XxXk*XxX***Xx* SECTION 4 - 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 **************xXX******X****X****X*XXX**X***x*****X*********X**X*x*X******x********X******* Ell 23 049 12/08 14AILING INSTRUCTIONS: TOLD IN HALF AND STAPLE. AFI'IX PROPER POSTAGE•. - , SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202