Laserfiche WebLink
a c r : r <br />UNDERGROUND TANK DISPOSITION TRACKING <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 hermit with number noted below is res2onsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: LJN 06PA,... �_Gj. (o Oi CE7 <br />FACILITY ADDRESS: ��� �. 1!`rT'Ll�.N t�•ttl lam• �}�24� <br />TANK ID #39- - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 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: _ 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 relulated by Department of Health Services. <br />SIGNATURE 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 />Address: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />Neill: UNDEIZGROUND TANK PROGRAM <br />BOX 2009 <br />STOCKTON, CA 95202 <br />