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SAN J©AiQL N LOCAL FTF.A IH DI SIX RI4= <br /> 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. The holder0 <br /> W 19 1990091ble for <br /> ensuringt t this -form ig coomp—leted and <br /> [' <br /> FACILITY NAME: J S S <br /> FACILITY ADDRESS: 5� Yliv� S74e �d <br /> TANK ID 139- <br /> SECTION - 2 -- Tobe 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 tilled 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 regulated 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 /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <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 j <br /> STOCKTON, CA 95202 ; <br /> is <br /> 'I <br />