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v ,r <br /> SAN JOAQLJIN LOC_AI� HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> W*W*X***WXW*WWW*****WW*W*****W**X***WWW****WW*XW*W*WW**W**W**WW***W****WWWWW*WWWXW*WWWW***W <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: !k7 +g-S MAI � <br /> L' H4 <br /> / <br /> FACILITY ADDRESS: C-) L n //lu� vS l �L /TIL PIQGVF_ <br /> TANK ID #39-�-� <br /> *X**W*****W*WW**W*WWW**W*W**X*******W**WX****X*WW**W****WXWW*****WWWXXXXWW*XW*WW***XWWWX*W* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: M aA S r ' � ( <br /> Address: I-PEHP- I LICE Zip: <br /> YhTrF- Ct C Phone#( 2mK <br /> Telephone: ( ) Date Tank Removed: <br /> *W**X*W****X***WW*W**W**W****W**W*W*WWWW*WWWWXXW*W**X*WWXW*******WW**W**WWWW******WWWW*W*W* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: 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 /> SIGNATURE AND TITLE <br /> *W*WX*******k*****X*WW*W*W*WWWX*WX**WW****X*W**WWW**W*W*W**W**XW*W***W*WW*WX*WX*XW**W***X*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 /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> **WX*WW*****W**W***W**W**W**WW***WWW*WWWWWWW***W*WWWWWWWW***WWWW***XWWWWWW*WW*W*WWW***W**** <br /> EH 23 099 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. BOX 2009 <br /> STOCKTON, CA 95202 <br />