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SAN JOAO IN LOCAL HEAT •TH 'I STRICT <br />UNDERGROUND TANK DISPOSITION TRAC1(ING RECORD <br />***xx::R**:*xt***ihftfefeR*ititxxft*x*******Rfexxxxxxx*xxxx**xttfcxxltxlt**xxR***x*Rx*************xxx** <br />SEXTION 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: Color S <br />FACILITY ADDRESS: 5400 E. Harney, Lodi, CA 95240 <br />TANK ID #39-- (;� <br />*****x***********xx***R************R********x********RRRR*R*RR******R*****R*R**xRxxxRx*RBBB <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM <br />Address: 351 N. Beckman Road <br />Box 357—, Lodi <br />p: 95240 <br />(209) 462-4581 <br />Telephone: ( ) Date Tank Removed: <br />*****R****x**R*xx*x*xxxx*xxR***********x*xRR*xxxxRR**xRRx*x*R*xR*xRR***R****R**R****R****x* <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: / P. 1'7,J' / i"i/il - <br />Address: <br />#: <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 />******************************************************************************************* <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 <br />Address: Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />zxxzx**z*x**z*zzxzzzxxx******x*zx*z*xxxzzx******z**zx*zzzzzzxzzx*x******xz**xzzxzxxzzzxxzxx <br />EH 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. O. BOX 2009 <br />STOCKTON, CA 95202 <br />