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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. e holder o the perm t with •+„mr,A,- <br /> en5urin4 that this form is moles�„� �„a , notes hotnr. +s rPaoorLihta f.,► <br /> - - urnect <br /> FACILITY NAME; <br /> FACILITY ADDRESS: ' <br /> M Iq iAj <br /> TANK ID 939- ^�- <br /> SECTION - 2 - To be- <br /> 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 may be regulated by Department of Health Services'. <br /> SIGNA7ME 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: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> �-''") STOCKTON, CA 95202 <br />