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SAIV <br /> UNDERCKYJND TA11K DlSbu51'I'fON TRACXING RDCORp <br /> kk*x*x*xfixxkRxfi*fi*x***Rxx*R**x xxxxkkxx*xx Rx xxxxxx xX*x**kfixk*Rx*xfi*XRRRxfi k**R**'k'R1111RRRlR1FRRR ' <br /> O -TION 1 - The San Joaquin Local Health District 's Trackinq Sheet will accompany each tank <br /> affixed with its site identification number . The Tracking Sheet is Co be returned to San <br /> recycling <br /> Local Health District within J0 days of acceptance of the tank by disposal or <br /> cecycling facility. "The hold <br /> ensuring that t 1 ��r of the oarm t wirh n ' �+ r nuFnrl tir <br /> _ h�_form 1g comolete� � rned • <br /> FACILITY NAME: Nnr-cal <br /> FACILITY ADDRESS: 1800 <br /> TANK ID N39- ID - �r o0o U�c�Ga�C <br /> xx*Xkx Rfixx Rkxfi Rx'x*****x****Xxx-�jx***RXkk xxRRR kxkfixx xR*Rkx RR*x*RR RRR Rxx R**RRRRx***RRR*RR <br /> SECTION - 2 - To be filled out by tank remuval contractor : <br /> Tank Removal Contractor : <br /> Address: <br /> _Zipi <br /> Phon95650 a <br /> Telephone : ( `J�) Date Tank Removed : . ? 916-652-5535 <br /> kR*xxx**Rxx*xR*******xX****xRRRRRkfi RRx*fifiRfixx RX Rx RRRRRfik RRfiRR*xRRRkkfiRR*R*RRRRRRRRR*RR1R*RR <br /> SSCT'ION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor : - �1 ervice <br /> Address : _ P.o 'Bo, 17; Z1p1 95650 <br /> Phone# : <br /> Authorized representative, of contractor cert : f .es by signing below tmt the tank has been <br /> dec tam ted n area prow d ner as may ce regula ed by Department of Health Services <br /> SI(.iNATVRE AND TITLC <br /> R xRRxx Rx**RRx Rfi Rx**xxxx Rxx xxxx kkkx kRxxxxx*xxkxx RX'Rxxkxxx xxxxx*kR*xfiRkx RRR R*RRRRRt Rx*RRR*x*R <br /> SECTION 4 - T and signed by an aurhorizLcl represnetative of the treatment, <br /> storage, or sal facility -a cepting carr. . <br /> Facility Name <br /> Address : <br /> PhonW IV4 <br /> Date Tank Received : <br /> RRR*xxRx R*RR*x***RR xfix Rxxx*xxxxkt*O*RRRxxkRxk�Rxxrt�M Rxk*DxxRTITLE <br /> Rx*RRxR RRxxxR Rk*A*RrRIRk RRRRR*Rx <br /> V( 2J 0,19 11/88 <br /> MAILING INSTRUCTIONS: TOLD IN HALF AND STAPLC. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A'71N: UNDERGROUND TANK PROGRAM <br /> P. 0, BOX 2009 <br /> STOCYTON, CA 95202 <br />