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SAN a0&LJIN LOCAT. HF'.AZA DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxzxzxxzz****z***z****xz*z***z*z**xz**xxx*xxxxxxxxxxxxxx*xxxx*x*xxxz***z*zz******zx***z*x** <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 ngmber noted below 1s responsible for <br /> ensuring that this form 15 completed and returned, <br /> FACILITY NAME: n'('nNkfr-r in)nnn`> <br /> FACILITY ADDRESS: <br /> TANK ID 439- <br /> *z*xzz**z***xx***x****xxz*z***xxxz**zxz***xxz*zxx*z**xxzz****zz*zxxxzx*zz**xxx***z**z**z**z <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 /> 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 /> SIGNATURE AND TITLE <br /> ***zz**x***z*z**xzx***xxz*xz**xxz*z*zz*xxz**xx**z*x*x*xxzzz*xxxz**zzx**z*z**xz**zxxz***x**z <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 /> *x***x***x*z*****zx*x**x*z**xz*x*zzx*****zx****z**z*****xx***z**xzz*xxz***xz***zzx**xxxzzxx <br /> EH 23 049 11/88 <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 />