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SAN JOAQUSN LOCAL HF'ALTH D2 STR2 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******************************************************************************************* <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 /> ME �l <br /> FACILITY NA <br /> : /4 P-60 f4C l Ll7y 02-07-o <br /> FACILITY ADDRESS: &0 - <br /> TANK ID #39- 1 - Qcri <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: r/LLAiLk <br /> Address: X0(9 S L4 PMa LU( l,�. SAS��l M 'A1 lL CA • _Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: S ic.W Q <br /> Address: S&M 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 /> SECTION 4 - To be 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 /> E11 23 049 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 /> STO KTON, CA 95202 <br />