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SAN 130A^Ti1w LOCAL HmAr rrl DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *****X*******************************Xx****xx*x*XxxxXX*kxXxx**xxx*x***X***x**xxk********xx* <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: SA3,4k1 <br /> FACILITY ADDRESS: j3;#tj) DA-l) —j_AACy Co- <br /> TANK <br /> dTANK ID #39- - �YMpy- }/t/�< ��xk <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ji M T_ 0� oe Di�{ �i✓C <br /> Address: �1• c �/vJ 9n/ �Za(, CoA; I"� zip: 9 ;_2-410 <br /> Phone#8091 3/�-6-/7S_ <br /> Telephone: ( ) Date Tank Removed: /o�a`/�F9 <br /> *x*x*******X******x*x***z*x**zx****x***x****************xz**xx**xxkxx*x*zzx**xx****xxx*xx*x <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: J;al 7A_D/Lpt Q k / AlOk -('�4- � �iy�,.S,glf� <br /> Address: kO 4z);A7n. n iei,Q J4 ) i tL6- Zip: 9j 1-yo <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 regulated by Department of Health Services. <br /> Ce�9 ice <br /> 3IGNATURE AND TITLE <br /> *************x***k********kX**k*****xXx***x********x*******xx*k**k*Xz***k***x*************x <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 /> ECHNITZER STEEL PRODUCTS CU. <br /> Address: 12000 FOLSOM BLVD. Zip: <br /> Qtfi-AF, Ain Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 099 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 />