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SAN .7OAQUIN LOCAL HAAT•TF-i D2 STR=CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> :t***xxxxxxxxx�rxxxxxxx�rxx*x*x**xxx***xx*x**xxxxx*xxxxx*xxxxxxxxxxxxxxx:r*****x**xxxxx�rx�rx,r,�** <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. of thew r noted l w ig r of <br /> ens10;ing that this foam is completed and r-eturned, <br /> y.T, <br /> FACILITY NAME: <br /> 1 � <br /> FACILITY ADDRESS: <br /> TANK ID #39- 57 30 - D 1 EN�P�NESLSH <br /> �***xxx*xxxxxx�cxxx**xx*x*x*xx�rxrr�c�rx�r�c�rx:r**�r�r***sx�t*****x�r�rxxxxxxx�r*rrx****x*�ci �R��X�e <br /> SECTION - 2 - To be filled out by tank removal contractor: 0" <br /> Tank Removal Contractor: DECON Environmental Services, Inc. <br /> Address: 26102 Eden Landing Road, Suite 4, Hayward, CA Zip: 94545 <br /> Phone#: (415) 732-6444 <br /> Telephone: ( 415 ) 732-6444 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: DECON Environmental Services, Inc. <br /> Addres3: 26102 Eden Landing Road, Suite 4, Hayward, CA zip: 94545 <br /> Phone#: (415) 732-6444 <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 /> SIQJATURE AND TITLE <br /> **xYtxx7kx*xxx�cxx****'k'kit*7��ir***�X:��*x*Yrx���**icx*Ycx*:tYc�Yx**�x**fix�icic**ic�Cxx'x�:r**irkic�Yrxx�rx***xx�x <br /> SECTION 4 - To be tilled out and signed by an authorizet3 represnetative of the treatment, <br /> storage, or disposal facility accenting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> A11THORIZED SIGNATURE AND TITLE <br /> *xxxxx****xxxxx�r,txxxxx�t*x***xxxx***�rxxxxx�r**x�r�c�rxxxx*t*xxxxxx****x*xx�**xxxx*****xx�r**xxx�cx <br /> Ell 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROM M <br /> P. O. BOX 2009 <br /> STOC{TO N, CA 95202 <br /> 9 • d ZS :60 63/01/80 wogJ <br />