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A. <br /> SAN aaAQUSN HEALTH DSSTR= CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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: P Fn h[_(> O 17 f( a i ftl Y S <br /> FACILITY ADDRESS: <br /> TANK ID #39- /SOS 3 _ 0/ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: C r / 5 j 1. O 12 �/ L D <br /> Address: O Zip: 3a 9 <br /> f h a 9 o a Phone#: 9 3Z- i K.1 S' <br /> Telephone: ( ) / Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: a //_� /_�* 0 <br /> Address: .� >, Rex /e l/ y/�/L _ Zip: <br /> ?< 3� I C�/�c 9 S �< �feti 9S1n5 Phone#: 9 �/-/ — <br /> Authorized representative ofcontractorcertifies 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 /> 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 /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 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. BOX 2009 <br /> STOCKTON, CA 95202 <br />