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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> U�DMgROUND TANK DISPOSITION TRACKING*RECORD <br /> ;k uin LoCaL Health District's Tracking Sheet <br /> _ q.t,e San Joaq its site identification n umber— <br /> SECTION 1 ffiXc-d with t0 San Joaquin Local <br /> will accompany each tans a be returned tank try disposal or <br /> Sheet to of the t noted above <br /> The Tracking of acceptance Permit with numbe xetuxned• <br /> District within 30 day e holder of the pe feted and <br /> recycling facility. that this form is Comp <br /> is responsible for ensuring Q� <br /> FACILITY NAME: Lauxa Scudders CA <br /> TANK ID #39-Wa-0- t <br /> FACILITY ADDRESS: <br /> L00 Val ico Road. Tra <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 1041 S. Pershing Avenue Phone # 462-9913 <br /> Stockton CA Zip 95206 <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "deco tAmi g tank": <br /> Tank "'Decontamination'" Contractor <br /> Address Phone# <br /> i <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 /> Facility Name 4! 8/InLsenl <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 2009 1 5T0CkT0nI I CA 96201 <br />