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SAN JOAQLTIN L0(_A2 � HAAT•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******************************************************************************************* <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: Harney Lane Sanitary Landfill <br /> FACILITY ADDRESS: <br /> 114750 Harney Lane, Lodi, CA 95240 <br /> TANK ID 139- <br /> ******************************************************************************************* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Az-"vAagu/YJ 40e2,� e A. llc &)er,-S <br /> Address: /B l0 E• /�Q?e��/9 IVF. S'�ac� i,`e� 4Sa0S zip: W-,ZeS <br /> Phone#: 468-3ce0 <br /> Telephone: ( ) Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <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 /> SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name Erl-4 5.01yj..rnc <br /> Address: ��'S AW- S/f/d 7Q1c/r0VnP , Ca.. zip: 175286/ <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ******************************************************************************************* <br /> Elf 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 />