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SAM .70A4W:rm LOCAL. IiE.AL`iI•D2STf22C3` <br /> UNDERGROUND TANK DISSPOSITION TRACLING PDCORD <br /> RXX*X*X*XX*X*XXXXXX***X**X*X*XX***XXXXRXRRXXXRX*RXX*x*xX*f�itXXX*XXX******XX*************XX** <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 he 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 wi h number noted below is reesponsihln for <br /> ensuring that this form is completed andreturned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: G� R a-7 <br /> TANK ID #39- ��0�J - 03> <br /> *XX**XX*X****X**R*X*XXXXXX****XX*****X*****X**XXX**XXX***XX*****X**XR$*XXX**XXX**X*X*XXX*x* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractnr: <a-M cC <br /> Address: _ \ tlTct P.U� . Mcx�1r s v a Zip: / <br /> Phone#: 2vfyg -2 <br /> Telephone: C/65 3 Date Tank Removed:_ <br /> *XXX*XXX*X*X*****fi*XXXXXX*X*X*XX*XX*XXX**XXX******X****XXX*XX*XX**XRfi*XXX**XX*X******XX**** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ;S <br /> Address: \ W . \�T�\ VSD, / \a�Ds``�� zip: <br /> Phone#: 'y_r2�iy 46s 3 <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 /> XxxRXxXXXX*XX*RxxXxxxXxXXXXXX*X**x*xxXX*XxXX*XXXX*XXXxXxXXXx**xXXXXxxXxXR**RXXXXXxXX*xXXXXX <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 -5 <br /> Address: y3\ �Z1 X727_)& 9Z CA zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ****X*X**RX**X*****X**X*X**X****X*X*********X***X***RX**7tXXXXX*****x*XXX***xRXX***XXX*x*Xx* <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIx PROPER POSTAGE. <br /> SAN JOAQU;:N LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTOtN, CA 95202 <br />