Laserfiche WebLink
SAN JOAQUIN L.00F,L, I �^ <br /> 3EAL,TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RE)OORD <br /> SECTION 1 - The San Joaquin Local Ilealth 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 tl:e tank by disposal or <br /> recycling facility, The holdu of the permit Wirl, ,,, I,,, F <br /> ensuring that this form Is. completed and reLu ned L, d w is cpn a►►,: <br /> FACILITY NAM:_ <br /> FACILITY ADDRESS:_LA5- I I JQ 01) <br /> TANK ID 139- �— <br /> i*R*#*t*RR*iR*****i#'R****R****A*R*A*Yk*R*Afi**R**R*****fi*****t**R***t*#******#*RR***R***R*#** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> (1�� <br /> Address: J Vis• x I Ul, I ig I I LI , �I f� <br /> Zip' `� J 1. <br /> I Phone l: l 1 b J 5 <br /> Telephone: ( ) Date Tank Removed: <br /> SEC"ION 3 -To be filled out by contractor "decontamin/ating tank": <br /> Tank Decontamination" Contractor: <br /> ��I�l 111 [ ll( Elul l /)STI )i ill <br /> Address: `SraIL1P Q ; Ca a�lllf Zip: <br /> Phonel: <br /> Authorized representative of contractor certifies by signing below thj t the tank has been <br /> decontaminated in an approved manner as may be regulated by Department- of Ilealth Services. <br /> SIGNATURE <br /> **AND <br /> iR**i#******R#**********i***#R*RR*R*#RR#** <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 Ca I ("ba t rln ni t-1 �rl��\n <br /> Address: ya[J vCr <br /> y . [ \0r kd / /" K tj —_Zi J3 l <br /> p; <br /> Phonel: )e, I <br /> Date Tank Received: <br /> **1YRRRi*RRR*RtiR***tRRR**R*R***It*#I****A*D***kN**j�JR*iAAD*RRA�A**i********A*******Rr***R#R***R** <br /> Ell 23 049 12/11 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL IIEALTII DISTRICT <br /> ATIN: UNDERMOUND TANK PROs nM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 i <br />