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ter' <br /> SAN 70AQUIN LOCAT• HFAr•TH DISTRICT <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 permit with number noted below is responsible for <br /> ensuring that this <br /> form is completed and returned <br /> FACILITY NAME: 2q�2z-- — cS/FnY X) �i9C r°_)r9/1 Cz7i�%7�e <br /> FACILITY ADDRESS:_ cS3� S �7Ji S'i. <br /> TANK ID #39- <br /> x****X***x***WxX*****X****x**************xW*****x******x*W**xx****Xx***Wx***x************** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: _/��� /`� _< f/.t)� Zip: <br /> Si7lC�>n �� 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 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: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <br /> 14AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGP.AM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />