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SAN JOAUU 1: LV LC���Al. H -' ✓ <br /> 1=.P.i�`I'H DIS1'F=LIC'T' <br /> UNDERGROUND TANK DISi-USITION TRAQ<ING RECORD <br /> xx*****xx*x**xxxxxxxxxx*xx*z*xxxxxz*xx*xxxxRRxxxXxxx***xxx*x*fi*xx**xXxxxwxxxxxrtxrtrtxw*x*xxxx <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 <br /> ensurino that this form is omol ted_and r�u ed wir ,r noted below i� esgo Lible fos <br /> FACILITY NAME; Nnr-cal Be:er <br /> FACILITY ADDRESS: 1800 ---- <br /> TANK ID N39- l (06 <br /> fixx*xrt*x*x*w***x'x**xfik**xrt*x*xx*xxk*kXxwxlfxRRRRXfi Xffxxwxxwxfik'X kxxfi*fixxx***fiy(*xxxx*fi*xfirtxxfi xx <br /> SECTION - 2 - To be filled out by tank remova_ contractor : <br /> Tank Removal Contractor : <br /> Address ; <br /> Phone# i 9565E <br /> Telephone: ( Date Tank Removed ! 916-652-5535 <br /> fi*x***x*xx*xxxxkxxx*xx*x*xxxkx*xfi Xxfixx*fi*xxxRx%*xwrt*xx*kkfi x*wxxx**x**w*k*****1t**rxxxx1111F*xx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" ; <br /> Tank Decontamination" Contractor ; <br /> Address: P.O. Box 17 ' roo.-. Zip: 95650 <br /> Phoneq : <br /> Authorized representative of contractor cert.f :es by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> fixxwxxxxxxxxxxxxxxxxxxfi*xxxxxxR'zxxxxsxxNxTUxRxxxDTITLE <br /> xxxxxzz*xxxx*xxxRxxx*x'rtxxRxxxxxxxxxxx <br /> SECTION 4 - To be filled out and signed by an aurhorizeu represnetative of the treatment, <br /> storage, or disposal facility accepting tar.,. . <br /> Facility Name <br /> Address: <br /> Zip; <br /> Phoneq ; <br /> Date Tank Received ; <br /> fixz*fixxxxrtxxfi*zx*x*xx*xxxtxwxXxx.zOx RxzxEDxxR_ZxxTxREE x rx AIfi*wxxTLzwxxzzx zxxxxxxxzxxx�+lrxxxxxxttr*xx <br /> Ell 23 019 12/88 <br /> MAILING INSTRUCTIONS: GOLD IN HALF AND STM LI . AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERCROUND TANK PROGRAM <br /> P. 0. BOX 2005 <br /> STOCKTON, CA 95202 <br />