Laserfiche WebLink
FACILITY NAME: IDLEWILD <br /> FACILITY ADDRESS: 3049 .'d. Hw7 12-Lodi, CA. TANK ID I <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> SECTION 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor• r e or t e� e m e 11 o s , <br /> Address• 30749 W. Hwy 12 <br /> Phone # <br /> Lodi, CA* Zip °5242 <br /> Date Tanks Removed No. of Tanks One (1 ) <br /> SECTION 2 - To be filled out by contractor "decontauinating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Sery <br /> SIGNATURE AND TITLE <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />