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- SAN JOAQUIN LOC"SPT• T-TF'AT•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> )TANK ID 139- <br /> *x*Xx****xxxx**x*XX*x#*Xx#xx*xxxx*x*Xxx*xXX*#*****##X**X******##xx***Xx**xXxX**#xX**X*x***# <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �E ../ <br /> Address: X70 v <br /> — fox Phone#: 9 <br /> Telephone: r�-,;o9 > /�'��-�?/S� Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractors <br /> Address: ��� cS i5i!'�fT� .a"l� Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be egulated by Department of Health Services. <br /> / <br /> SMATLWAND TITLE <br /> *x*#xxxx*x*xxxxX***Xx*#x**x* xX*X*x*#x*x*x x*#x**#x**xXX*Xxx*#x******x##*X**x#x*xX****XXX#* <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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED`SIGNATURE AND TITLE <br /> 4*xX*x*XX**x**#**X**xx***************X**#xX*x****X*X#*********x***x*#*X*******X*#X*##XX*X** <br /> :H 23 049 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. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />