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1 <br /> SAN JOAQLJIN LOCAL, HFzar.TH DSSTRSCT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *!**#**i***!*#***k**i <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 oermlt with number noted below 15 r an•QnSib a for <br /> ensuring that this <br /> �� form isCgmple ed a d r irned, <br /> FACILITY NAME: f 11_2gellq /fJ� ,f A-) -F/>FL 74, <br /> FACILITY ADDRESS: <br /> TANK ID #39-_ 1, - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> 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 /> **X*******!k*!*!k!!**k*X!k*k*k**k**k**XGNk**TUk lEtk*kxD**kXxk*kk*k****k*!k**k***k#*kk*#k****k*#*k <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 <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Uk*kOR***xDkk*f24XkTLIR***A**Dk*k*T** <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. 0. BOX 2009 <br /> STOC7CTON, CA 95202 <br />