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SAN JgA�UI:N L.C�C�AL, HEAL, H DISi'1tICT <br /> UNDERCROUNU TANK U:J ;;;!": !t)N TRACY 1 NG RECORD <br /> kx***fi*xfix*x%%X*x*%*fix*kxx%**xxxxx%*%X%x%*xxx*xxxx**x*xxXxXkxxxfi xx%*%*x**x**fifififiMfi*fifi Y;Ytfififi <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 clays of acceptance of the tank by disposal or <br /> recycling facility, The holder Of h <br /> ensurin - r C r rh n ned r noted below 1;i .�c ap <br /> Q _t_hat this form is lotFrl anae. ibl Or <br /> FACILITY NAME; Nor-Cal Sever::_, <br /> FACILITY ADDRESS: 1800 "E" Fromon' <br /> TANK ID N39- (I) - Z P,00,D <br /> xX**xxxxxx*x%**x'fi**xXx**x*XxxxxXxx***xxxxxx. r , ,,xxxxrxxxxxxxxxxxxxxxxx**xxxR**RRtRx*xfi7r1Y*** <br /> SECTION - 2 - To be filled out by tank remova_ contractor : <br /> Tank Removal Contractor : <br /> Address: <br /> Phone# i 95Ef'e <br /> Telephone: ( ; Date Tank Removed ; 916-652-5535 <br /> x*x**fi**fifi*%*x x— R�*fi*fi*%)*%%fi*xx%%x*xx%%k*xxxx*%xxx**%X***%Xxx%X***X****k*xxk*Rflwtt**fi*X x•71** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor ; <br /> Address: _P.O. Bo 70 0o Zip; 95650 <br /> Phonek : <br /> Authorized representative,of contractor certifies by signing below tttiit the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services , <br /> x*xxxx%x%■xxx*x*xx*xXXxXx%xxxxxxxxxxSIGNATURE <br /> xxxxxD%x**xxxxxxxXx%*Xx**xxxxxxx*xxx*fifififixfifffi7txxfi <br /> SECTION 4 - To be filled out and signed by an aur.horizeu 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 /> a�A <br /> xxkk*xxx**x%*x*x**xx*x%Xxx*xxxxYtxOx Rx x*xDxxxRxx"�x�xxxxxw lx xx*%x%xxxxxx*x%**X�'kxxX**IF*1'*** <br /> Elf 23 019 12/88 <br /> MAILING INSTRWrIONS: FOLD IN HALF AND STAPLC, AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM; UNDERGROUND TANK PROGRAM <br /> P • O. BOX 2005 <br /> STOCKTON, CA 95201 <br />