Laserfiche WebLink
;�: ' SAN JOA!Q� LOCAL. HE'.AI�THSTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> zzxzzxzxxxxxxxxzzxxxxxxzzxxxxzxzzxzzxxxxxxxxzxxxzxxxxxxxxxxxzxxzxxxzzzxxxxzxxxxxxxxxzxxxxxz <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 noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: �'� L Q G -S�� /A-� i <br /> FACILITY ADDRESS: �� S VQi LrL2�� SZ/��/ C� c7J Zr3 <br /> TANK ID #39- <br /> z*xzzzxxzxxzxxzzxzxzxxxxxxzxzzxxxxxzxxzxzzzxxxxxxxzzzxxxzzxxzzxxzxzxzxzxxzzxxxxzxxxxzxzxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> ******z*xx*x*****xx***xzzzxxxzxxzzxxxxzxzzzzxxxzxxxxxxxxxxxxxxxxxxxxxzxzzzzzzzxzxxxxzxxxxxx <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 /> **xxx***x***xzx*x*****xxx*xx*z**xzxxxzxxxzxxzzxxxxxxxxxxxxxxxxxzxxxxxzxxxzxzxxxxxxxxxxzzxxx <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 <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> x*xx*x***xx****x*x****xx**z*****zxx****x*xzzxxxxxzxzxxxxxxxxxxzzxxxzxxzxxxxzxxxzxxxxxxxxxzz <br /> EH 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 />