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• <br />0 <br />S ALV a QAQU I N Y10(—_A HEAL.'rH D I S TR I (—= <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 nays of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted below is responsible for <br />ensuring that this form is com leted and returned. <br />FACILITY NAME: M - ) C r) j /U & <br />FACILITY ADDRESS: -- <br />TANK ID #39 - <br />SECTION <br />39 -SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: 1L_ 1 i�,'Li V1 B L. "� l <br />Address: 's C_ C Zip: <br />Phone# : a� A -5 k, l i <br />Telephone: ( } Date Tank Removed: <br />SECTION 3 --To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />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 />S IGN'ATURF, 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: Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Elf 23 049 12/88 <br />NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPK� 90STAGE. <br />SAN JOAQUI N LOCAL E EEEALTH DISTRICT <br />ATTN : UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />