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S2U'J Jf�z,OT JI1V LOCIAT " HF_AT H D'2 STE22 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxzxxxxxxxzxxxxxxxxxxzxxxxxxxxxxxzxxxzxxxxxxxxxxxxzxxxxxxxxxxzxxxxxxxx***xz*xxxxxxxxxxxzxx <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 hpermit with number noted1 <br /> ensuring that this form is completed and returned <br /> , y5k�p��4 Lj 4!�tu <br /> FACILITY NAME: c7ph Rt 4 X1-265 SEP 211999 <br /> FACILITY ADDRESS: COCK le,4� Z0,9 J <br /> TANK ID #39- _ PERMIT/SERVICES <br /> xxxzxxxxzxxxxxxzxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*x**xxxxx*x**x*xxx**xzxx**xx*x*xxxxzxxxxxzxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: M TA-6OZ-Pe (9ik, Z-AC_ <br /> Address: 3S/ N. Adec�sn*A✓ leas 1-0d) (',o Zip: 9�aYo <br /> Phone#: 9) 3ot r,nS <br /> Telephone: ( ) Date Tank Removed: VISOY <br /> xxxxxxxxxxxxxxxxxxzxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxx****x**xxx**xxxz**x*xxxzzxxxxxxxxxzxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> KL � <br /> fTank Decontamination" Contractor: { 4te <br /> Address: 2 / W, �,rr yr✓ L ^J L'fy Zip: <br /> Phone#: tdgj 3G*-/oi7T <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be r gulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> xxxzxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx**xx*x**xx*x*x*x**xxxz*****xxxxxxxxxxxxxxxxx <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 /> 12S�OOM 9B <br /> 000 FOLVD. <br /> Address: RANCHO CORDOVA CA 05742 Zip: <br /> Phone#: <br /> Date Tank Received: �/_� <br /> AUTHORI ED SIGNA AND TITLE <br /> *x*xx**x***x*xx*x***z*xx**z**xxxxxxxxxzxxxzxxX *xx**x***x***xxxx*xxxxxxxxzxxxxxxxxxxxr.zxxxx <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 /> STOCKTON, CA 95202 <br />