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SAN .JOAQUIN LOC"-AIS H=AT•TH D2STEzlCT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 <br /> form is completed and returned. <br /> FACILITY NAME: /� (SC0f4C1( l7y 207(o <br /> FACILITY ADDRESS: &0 X 1457 -�E11c g N4,4,1 (, P;, _ — LO p) (0 k— U klt. <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:— El LLA1151 . <br /> Address: _AO f S g�4P0al OLtJO L). S4C_AeA�-fOnglC� cA . Zip: <br /> Phone#: q/(, -372 - (jf Kc; <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: S 2LW k <br /> Address: Sc3."Q Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below tYkit 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 /> Elf 23 049 12/88 <br /> tIAILING 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 />