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SAN 'TO- "2UI N LOCAL HEAT.'T 1 DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xx*xx*xX**X*x**X*X**XX*****X**XXX*X***XXXXX*X*XX*XX*XXX*********x*X***X****X**********X*X*x <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 Permit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: c J E �r'r c' l��'c• <br /> � r�. ec an:uiin Disfricl R2Q5 <br /> FACILITY ADDRESS: . ;�� O G'G�, C�E?/7�� �J��i (S 3654 V,1. rnfinl <br /> TANK ID 039- 77e�1/2-c- <br /> Tracy, CA. 45376 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: rJi ny <br /> Address: ,3-135 -Teeee C� . Ly-r. !< Zip: <br /> 6A gSa 05 Phone#: <br /> Telephone: (—_) 94 8 (PIawl Date Tank Removed: <br /> **Xxx**X*X*X*X***x****x*X*X******X**X*******X*******X*XXX*****x*X***X*******X*X*****X*X**** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: -To,cinc,2a1 <br /> Address: a= C �'d Qve- Zip: <br /> kyr d o meA Lu Phone#: 4 I (o Q l 1440 <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 /> *********X*X***X****x**********************X**************XXXX*XXxX*X************X***XXX**x <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name 1 ri,arla IP, -Trio <br /> Address: 2 Nd QUe- Zip: <br /> Q "r"Vlf�ilFn !w Phone#:qka Uall 2 ,?n <br /> Dat✓\ Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *X*****xX*X******X****X***X***X*XXX*****X*X***X*X*X*XX**X**X*X******X*X*X*X*X*X**X*Xx****X* <br /> EH 23 099 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />