WORK PLANS - Laserfiche WebLink

Home Browse Search

f,T SAN JOA�x•72 N LOLL H 1 z " ~ . LINDERGR -D TANK DISPOSITION TRACKING RE tD ' ' �rt�rxxxxxxxxxttxxxxxx*x*xxxx*xxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxxx*xx�xxxxxxxxxx*xt****rtxx::xxx SECTION I - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the pgrmit with number noted below i§ reapgnslble fyr-_ mmina that this form is completed and returned, FACILITY NAME: gP-0C q C.— FACILITY ADDRESS: Z �_✓ TANK ID #39- xxxxx*xxxxtxxxxxxxxxxxxxxxxxxxx*xx*xxxxx*x,�xxxx***xxxxxx******xxx�r*xxxx*xxxx*xxxxxxx*x*xx** SWTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor:,W C TCA6t "� SQA-✓'K i. A/�- -- Address: MIR V Td Zip: Phone 0: Telephone: ()) Date Tank Removed: xxxxxxxxxxxxxxxx* *xx* xxxx*xxxxx*****xx****xxx*******xx*****xxxx****xxxxx*x*x****xx*****xx SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Q , Address: )---73D77 iP � ✓ S1rOG/��1 Zip: Phone#: 1 Authorized representative of contractor certifies by signing below that the tank has been I decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE xxxxxxxxxxx*x�rxxx****xxxx*xx**xx**xxxx***xxxxx***x**xx*xx****xxx***xxxx**xx***xxx****xxxxx* SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, J storage, or disposal facility accepting tank. Facility Name Address: Zip' Phone#: Date Tank Received: AUTHORIZED SIGNATURE AND TITLE xxx*xxxx:*:*xxx*xxxx*x*xxxx*xxx***xxxxxxxxxx*xxx*xx*xx**xxx*xxxx*xx*xxxx**xxxxxxxxxxxxxx*xx EH 13 049 12188 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE• AFFIX PROPER POSTAGE. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM p. O. BOX 2009 STOCKTON, CA 95202