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SALV JO IN .7%. STRICT <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 not low J3 respgnsible for <br /> ensuring that this form is completedand returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:—] <br /> TANK ID #39- - � <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> {{� Y <br /> Tank Removal Contractor: CJ Y i ( '. jl () ~Yr)C(L4 <br /> Address: . <br /> _ Zip: <br /> L2 rhtii Phone#: <br /> Telephone: ( yl 1 Ce)� [ Date Tank Removed: <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 /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name r� <br /> Address: , . C rr C Zip, <br /> ' Phone#: <br /> Date Tank Received: ; <br /> AUTHORIZED SIGNATURE AND T <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AWN, UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />