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SAN J OAQU I N LOCAL HEALTH I7 I S TR I CT <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 NAMEi c 7r 1,c'v ire c,-_c4.0n "2 <br /> FACILITY ADDRESS: <br /> 3C? L Cram'`ne Rd . arae; , 95 7 <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 6c—_NLC L% <br /> Address: ti31 kO- 4-A-Tr,int zip: 6Z 3S1 <br /> Myo TD �.a Phone#: :2cxf- 5149L.>_3 <br /> Telephone: ( .2y`i Date Tank Removed: <br /> x***x**xxx*****xx*x**xxx***xx*x*x*x*************xxx**x*xx**x***********xx****************** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ' ic>M C U <br /> Address: Q_3 w ATG=tt AAA90BST61 _ CA Zip: 'i z, 3 1 <br /> Phone#: 2er o1.g - `iG5_3 <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 /> 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 Lam; n/ wT.t=T'4 t�S <br /> Address: Zip: <br /> /71771 -oAz _ � I Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <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 />