Laserfiche WebLink
SAN JOAQUIN LOCAL H1,M6TH DIS'r'3ICT <br /> \./ 1%0d <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned, <br /> FACILITY NAME: Laura Scudders <br /> FACILITY ADDRESS: _L00 Valpico Roads Tracy, CA TANK ID $39-I 3-2 1/6)00 <br /> SECTION 2 - To be filled out by tank removal contractor: e <br /> Tank Removal Contractor: Areai.9jnn Tnf1i_g -rim_q' Tnr• <br /> Address: 1041_S. Pershing Avenue„ Phone 1 462,-2911 <br /> _Stockton CA _ .. _ Zip. 95206 . -- <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor___._ <br /> Address /Phonel <br /> Zip <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. <br /> Fac i 1 i ty Name die/C�S47� _ <br /> Address phone$ <br /> Zip <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P.O. BOX 20091 STOC 1CTo N / CA q!52-01 <br />