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SAN 1jOAQUI N Z.,Ot"Z • HmZk •TH n11Stl'R I C'I' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD AUG 25 1999 <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet `iY�E tank <br /> affixed with its site identification number, The Tracking Sheet is to e$ to San <br /> Joaquin Local Health District within .30 clays of acceptance of the tank by disposal or <br /> recycling facility. The holder of the pgrmit with number noted below is respgnsible for <br /> ensuring that this form is completed-and returned. <br /> F'ACI L I TY NAME 4L2 <br /> FACILITY ADDRESS: // '16 j i`c"�. <br /> TANK ID #39-- 1 L/'� LP - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: �" �s .� C. C�_s 3z ? zip: �� <br /> Phone#: 2 <br /> Telephone: (��' c, ) s mac/ 7 �' " `' Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor �,_(lC� <br /> Address: z - �/� �. Y e - 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 /> SIGNAIIAE 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 <br /> Address: C Zip: ^ <br /> 3 <br /> _ Phone#:;:'- S s 7L 3 ? , <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E!1 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 />