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/Affixed <br /> SAN a7 -0 .QUI1V L6CA'r• 1-i�v.Ct nl -ga 'xC`r <br /> UNDRAGR0UND TAMC DISPOSITION TRACKING RECORD <br /> ION 1 The Ran Joaquin Local health blattict's Tracking Sheet will accompany each tank <br /> with UN alto 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 of <br /> rec"XIIng facility. 1ffihQlder of the oermlt vith nmber noted below !a rearwnslble for— <br /> •naLina that this form Is ctmoleted and returned <br /> !'ACLLITY NAM 4r„c_� to01 G—toLt <br /> FACILITY ADMM111 38 D C) L3 E---A- CO tin 7Y c� C Ca l 3 '0 V 1 V - <br /> TAMC ID 139- <br /> #1AAAARARRARAR#RR#RRAR#A#ARRAAA##RARRAAARARAR#RAAAR#AARAA#R#AA##*A#R##AAA##RA#RR#*RBBB*RRAR <br /> MWTION - 2 - To be filled out by tank removal contractor: <br /> Tank Rer val ContrActort S 2,-�cco ��rsnc rr�rtc �1 -.ems t `c. <br /> Address 4�ti u.U�c z1ps G'SaC,� <br /> Phone#: <br /> Telephoner (1.2a_) q(,q 3 3 3 Date Tank Removed: <br /> R#RR#A#ARRRAA#RRR#ABR#R#RRA#RAR########A#R##A##RR#A##ROAR##*RRR*R#RRR####AR#ARA**R*R**R**RR <br /> MOCPION 3 -To,bs filled out by contractor "decontaminating tank": <br /> _ TAnk Decontaminatim" Contractors <br /> 1 Addreast 2sr CL vr3 zip: <br /> «H M6 o.n 0 CA Phone A: - _Z S SS r. <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 /> SICHAIMP AND TITLE. <br /> ARRR#BARK#RRR#RRR#R#RR##AR###BARB#ABR########R####ABR#RAR#RAR#ARRRRRR####R#RRR#*RRRRARR*RAR <br /> OWTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> leclllty Name FF iC cp( k) - <br /> Asldresst _ zip: <br /> Phone#: <br /> Date Tank Receivedt <br /> AUTHORIZED 9IGHATURE AND TITLE <br /> RA��RRARRRRRR#RRRRARARRRAARRRRRRRRRRRRRRRRRRR#R##A#A#R#R####R##RRRAR#R###R#OAR#AA#R#ARARRRR <br /> BH 23 019 11/11 <br /> NAILING INSTRUCHONSt FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTTI DISTRICT <br /> ATTNs UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOM", CA 95202 <br /> t <br />