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SAN JOAQT TSN :LOC_,2- HI•✓ALTH D'S S.TE22 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING REbEI2D <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 Jan t <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 form is comoleted and returned. <br /> FACILITY NAME Cb. p <br /> FACILITY ADDRESS: /6l7 he kt� ky a." LCYX <br /> TANK ID 139- <br /> SECTION --2-- To be-filled-out-by tank removal contractor: <br /> Tank Removal Contractor: VjesteYi t "j e•{ e j Se✓✓� C� Lire . <br /> Address: 1735 ieePee. i)ic �;7j-e A, Silyekkei Zip: 9S2os <br /> Phone# : — <br /> Telephone: ( ) Date Tank Removed: <br /> *zzzzz******z*******z**********zz*z*z**z**z*•zz**********z*.�*****z*zz*z******zzz*zz*z******* �;: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" contractor: 44jf.St VL4 <br /> Address: X735 I-ebePee04 STE i 5100 ,4_45," 2ip: !2-0572e <br /> Phone# : 'hJ9X b/ SX <br /> Authorized representative of contractor certifies by signing below that the tank has been A n <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <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 2 - TJGt rr <br /> Address: 2ip• 5y, <br /> Phone# : <br /> Date Tank Received: V <br /> AUT14ORI2ED SIGNATURE AND TITLE <br /> EH 23 044 12/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATV: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />