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SAN .70AC2UIN LOC..AL H1=nT•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> zxx*zz*x*x***zzxzxxz*x*z*xx****x**xxzz***zz**xx***x*z****z*zzx*z*z*x*****z*xz**x******xxzxx <br /> s�=ON 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 Is completed and returned <br /> FACILITY NAME: Cf1ElJ�0i[/�IJS� <br /> FACILITY ADDRESS: �'-�'�7 �iY.s'�T�IZ lyk <br /> )TANK ID #39- j�jt _) o t <br /> xx**z****x***zx**x*zx**x**z****xx*zxx**x**********zzx*z**zzx*x**x****x*****zx*xx*xxzzx*zx** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Z, :0a 6: ! S'T. ���11'��i7✓✓ Zip: 7: <br /> Phone#: <br /> Telephone: X09 ) /���-�7/S Date Tank Removed: <br /> xx**z***xx*z*z*z***z*z*x****z**zx**zx*******xz****xx**zx***x*x*z******x**zx**xx**z********* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may r gulated by Department of Health Services. <br /> EX f[.�iT�2 <br /> SICK AND TITLE <br /> **x*xxxxx**xx****xx*x** *xx***xx******x**x***x***x***********x****x**********x*x********** <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 <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED`SIGNATURE AND TITLE <br /> sx*x*x**x**xx**********x***x**x******z*********z*******z**z********z*z**********z***x**x*** <br /> 311 23 019 12/88 <br /> SAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />