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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> t t t t ! t R t t t R t R t x t * * * t * R x x t * R t t R t t R t t <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: BJJ Company, Inc. <br /> FACILITY ADDRESS: 2931 E. Mariposa Rd.,Stockton TANK ID 139- V7 Ov(jgfz Ur ( <br /> t t t t ! t R t ■ t * R R x R x R R R R t * R t R t t t t R t t t t t 7` <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor;_ APC,5I� T. 6 -L1" <br /> Address:_ /O'// $'. r�rs�r��c� Phone 1.1a?- %61 99// <br /> ��nrl<fa. CfF Zip <br /> Date Tank Removed <br /> t R t t t ■ t ■ t t R t t t R R t * t t t t R R t t t t t t R R R t t <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Authorized representative of contractor Zip <br /> certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> t t t t t t t R t R R R R t t * * t f t t t t R R t t t * * t t t t t <br /> SECTION 9 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 1 t t t t x R R * R R * R R x R * t t t * * R R x x R t t t R t t t R <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 , 5Toc k,TON , CA 9S201 <br />