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SAN a02*"UI N LOCAL HF'AT.��r,� D2 S'1�2 CT <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-holder of the Dermit with r noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: 'T' <br /> ) <br /> FACILITY ADDRESS: 02 GG G� E 7►-d S- <br /> TANK ID 139-'� -�-7 7 - 0/ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:liV Tart,✓ dAaZEM S��y���cS <br /> $v„r T-c E <br /> Address: <br /> c-� T C ,�- Zip: 2 0 <br /> Phone#: _�S/� <br /> Telephone: ( )_ 5��- G/Z Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Ild ESTETZW C��T1, �'c�1✓!Grp /.� „;_._ <br /> Address: <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 INSTRUC'T'IONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />