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-3UL - 2es W EP 1 a 1 5 MOORE PETROLEl ' M P - 0 <br /> SAN OAHU I N LOCAL, HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RDdORD <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 p alt with number noted below s respgrisible for <br /> ensuring that this form is completed and returned, <br /> FACILITY NAME: �" 4'-j � S �-X X U,v �- <br /> FACILITY ADDRESS: )3 `19 t�_ YO 51 --1 , /4U /�I/ /� C-A - �I 3 3 <br /> TANK ID 0 39- <br /> SWrION - 2 - To be filled out by tank removal contra <br /> Tank Removal contractor: r— <br /> i <br /> Address: L /v /��lf 1 ✓ Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <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 filled out and 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 /> Fit 23 049 12/80 <br /> MAILING INSTRUCTIONS: TOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQU I N LOCAL, HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />