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SAN J0A(2UIN LOCAL HEALTH I-jISZ'I2ICT '� <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> IECI'ION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> iffixed with Its site identification number. The Tracking Sheet is to be returned to San <br /> ioaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />:ecycling facility. The holderpermit y1th number noted below is responsible fol` <br /> auring that this form III r <br />'ACILITY NAME: �FAJ��I� 1�c)Aj <br /> ACILITY ADDRESS: rl3 M <br /> ANK ID 139- <br /> ECPION - 2 - To be filled out by tank removal contractor: <br /> nk Removal Contractor,�://`�(��-��'/��'Yz1-� <br /> c fV0 - C� 4/l�i� Zip: <br /> dress: LEJ� <br /> Phonel: <br /> elephone: _( ���/ )'�6 c�3 Date Tank Removed: <br /> ECTION 3 -To be filled out by contractor "decontaminating tank": <br /> nk Decontamination" Contractor: <br /> Address: 4 Z [ <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 /> k*****k****R*********k**k*********k*k*k**k**********k***k*k**********k***k****k************ <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment;- -- <br /> storage, <br /> reatment;—storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 13 O49 12/88 <br /> MAILING INSTRUCPIONS: 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 />