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SALT 0OAQUIN LOC -AT. HEALTH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />xx**x************x*x*x****x**x**xxxx*****x*xxxxxx***xxx*xx******xxx**k*xx*x*****x*x****x*xx <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 permit with number noted below is responsible for <br />ensuring that this form its completed and returned. <br />FACILITY NAME: /7^ 111� <br />FACILITY ADDRESS: 1777 'F14 eL'n y�✓' 'Sr STf%`� C' f�i/ <br />TANK ID 039- �'✓ ' - <br />*******x*******x*x*xx**x**xxx****x*x**************x*x*x*x*xxx*xx******x*xxxxxxxxxx****x**x* <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address:%3i �c,UN id Kim C ) ��'i'' %f /iF Zip: <br />/ Phone# : 2-01 <br />Telephone: (224P Date Tank Removed: <br />***x*xxxxxxxxxxxxxxxx�*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: �C'J�e'�?-'� /sr�<7�'�C sr'h v"e- <br />Address: Zip: 9�� `r <br />Phone#: �! y, = /.J -Z <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved _nner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />k************x*******k******k***k*xx****k**xk****x*********k****************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 <br />Address: <br />Date Tank Received: <br />Zip: <br />AUTHORIZED SIGNATURE AND TITLE <br />**x*xx***xxxxxxx*x**x***********x**xxx******xx**xx**x*****xxx*****x**xx**********x********* <br />EH 23 049 11/88 <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 />