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SAfI JOAC2LJ I N LOC.2�L Hi�'11L1 r3 I7 r s 7 R=C`I' <br /> LkiMGROUND TANK DISPOSITION TRACKING RECORD <br /> y <br /> yearl, tank <br /> ON 1 - The San Joaquin Local health District's Tracking Sheet willaccompanyed 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 holdrr1 the permit y1th n,Mtvr noted ►plow is ren pottslble for <br /> uring .hay this fora its completed and teturned. <br /> FACILITY NANEt (-16( r �-' C ' « 7cC_i L�_• y>\\ <br /> FACILITY ADDRES91 -2 ' C-1 L3 <br /> TANK 1D 139-J y l -- 0 <br /> RRR#Rf1tRRRlRtRRRRRNRRRRRt#RRRRRRRRRR#tR###*RRR##RR*R#tR*##***#R**#*R*#*RR**R******k*kR**R*R <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractort <br /> Addreast <br /> c Zlp: 4'SacS� <br /> Phonel: <br /> Telephone: (30�(_) ZIUA — 2, Date Tank Removed: - <br /> RRR.���RRRRRRRtRRRRR#R#RRR##RRRR#R#RRRRtRRRRRRR##RtRRRRRRR##R*R#*##k#R#****#*R*#k*k*RR*#k Rk <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontaminatio((n" Contractor: F rlc�se J —nom• <br /> Address: o2FS TSP r� -Zip: <br /> C-N W lry) CR Phonel: 4 d-5 S <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as stay be regulated by Department of Health Services. <br /> 9IONAIME AND TITLE <br /> RR##R#RRRRRRRRRRR#R#R#R#RRRRRtRRRRRR###RRR##RRRRRRR##R*R#*##Rk*R##*t#*k**#k*k#Rk*RR*R*RkRRR <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 IC_cx0� -- <br /> Addresst Zlp: <br /> Phonel: <br /> Date Tank Received: - <br /> AIICHORIZED SICNAIMP AND TITLE <br /> #RRRRRRRRRRRRRRRRRRRRRRRRRRRRRR#RRRRRRRRRRRRR#RRRRR#R#RR#t*tRR#*RR*#tR**#*R***R*k**k Rkkk RRR <br /> eN 23 019 12111 <br /> NAILING INSTRUMONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAWIN LOCAL HEALTH DISTRICT <br /> i ATM- UNDERGROUND TANK PROGRNI <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />