Laserfiche WebLink
SAN J'OAQUIN LOCAL HMI. LT TH DI STRI 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 thisform is completed and returned. <br /> FACILITY NAME: A (SCO r-4C I Ll7`/ Af207(o <br /> FACILITY ADDRESS: &0 e5AS7 1L,�517La)`f,Q!I U4Pe- - LOP) 4 k- V_ <br /> TANK ID #39- L-3 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: r/LLA115- 2 60' W-lk"16� / <br /> Address: A06v SL4POLf 13LU0 1A). 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 a"IR, <br /> Address: 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 /> Ell 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 /> STOCKTON, CA 95202 <br />