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SAN JOAQU I N LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *X**X******x**XX*****************WW**WWW*xWWWWWWXW****XX*xWWWWWWWWX**XWxWWWWWW****WWWWWWW** <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: 7Thrf) <br /> Ce— rC4L ) ev)�5/ G ro Ce f'�C <br /> FACILITY ADDRESS: 6 -73 �• VV 0. 'Ud �G�� S !y� <br /> 6Gk-7o n <br /> TANK ID #39- X30 - ) <br /> x****W*W**W*WWWWWWWxWWWX*WWxxxxxWWW**W*WW*WxWWWWWWWWWWxWWWWW*W*X*xW*X********XW**xWWWWWWxW* <br /> SECTION - 2 - To be illed out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Removed: <br /> ***WW*WxWW*x***X***WWWWWWWW***X*****X*X*WWWWWWxW**x* *XX****XX***X*WWWW*WWWWWWWWWxWW*WWWW <br /> ]� SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractors:: C r C C 1 5 I o Vi -1-in ku5+r i S <br /> Address: !O If s 5. Pe- 5k 1 rC4 Zip: p � <br /> � c_ n Phone#: NH a _ q F-I �— <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 /> WWWWx*****W*W*x***X*WWWWx*****xW**WWWxX*Xx**x**WWWxW****x**X***X*WXXWWWWxx*xX*k*xxxx******k <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposa acility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ***WWWXXW*****WWxWWW**XWWWWW*x**WWWWWWW*W*****WWWWW**XX***X*XWWWWWWW****XW*XWWWWWWWWWW***X* <br /> EH 13 049 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. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />