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- SAN JOAQUIN LOCAL i-IF'nr.TH DSSTRICT <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 nUM12tr noted below is responsible <br /> ensuring that this form is completed and returned for <br /> FACILITY NAME: <br /> FACILITY ADDRESS <br /> TANK ID #39- <br /> x***1kx****x***]kX'%k*****************k*x*****x1tN*x********lt**%******X'****%1t%**%*****kX**x**%}, <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> 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: <br /> Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as nay be regulated by Department of Health Services. <br /> - GN*xUR*xzrNcDxx*xx%%**xx*x*X***x**xx***xx***x**%******* <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 <br /> - Address: <br /> Zip: <br /> Phone#: <br /> _ Date Tank Received: <br /> UT**O*R**xD***ax%*fax**xxD*%xx*%*x*******%*****%x*x%***x*%x*%*% <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />