Laserfiche WebLink
SAN JOAQUIN LOCAL HMAT•TH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />xxxxxxxxxxxxxxxxxxxxxxxxxxzxzzxzxxxxxxxxxxxzzxxxxxzzxxxxxxxxxxxxxzxzxzxxzxxxxxzxzzzzxxzzxxx <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: <br />FACILITY ADDRE <br />TANK ID 039- "1 <br />xzxzxxxxxzxxzxxzxzxxxxxxxxxxxxxzxxxxxxxzxxxxxxxzxxzxxxxzxxxxxzxzxxxxxxxxzzzxzxzxxzxxzxxzxzx <br />SECTION - 2 - To be fil.4-ed_out by tank removal contractor: <br />Tank Removal Contractor <br />Address: <br />Zip: c-o-,�o <br />i4/S) �S7Z-fXoC.3. <br />Te lephone : ( 415 ) $72 - O( -(o 3 . Date Tank Removed: <br />zxxxxxzxxxxxzxzxxxxxxxzzxxxxxxxxxzxzxxxxxzxxzxxxxxxzxxxxzxxxzxxxxxxxxxxxxxxxxxxxxzxxxxxxxxx <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: i <br />Address: Aiv: l l-1 - -�t1 71P: <br />Authorized representative of contractor certifies by signing below thkit the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />xxxxzxxxzxzxxzzxxxxxxxxxxxxxxzzzxxzzxxzzxxxxxxxxxxxxxxxxxxzxxxxxxxxzxzzxxxxzxxxxxxxxxxzxxxx <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 f 4 4 L cJV rc. � i � ti �A l /1 <br />Address: ' c �Q�; a-..aS�J �AW �PA-o 4,ScC0 l',ui - Zip: <br />Phone#: 4±!i -543 - 4sr3c <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />***xzz**xx*xxxxzxxxxzxzxxzzzzzxxxxxxxxxzxxxxxzzzxxzxxxxxxxxxxxxxzxxxxxzxxxxzxxxxxxzzxzxxzzx <br />Elf 13 049 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 />