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SAN JOAiC1UIN LOCAL <br /> HtTssr.TH DI SZ`FtI C'J'T <br /> 0 UNDEpMOU7D TANK DISPOSITION TRACKING RECORD <br /> Rflt}}A}Rf!}fRlRftRR}t}AflfARlffA}#!}!f*!A#}#!A!}}#}f}Aff}f#!!*At}RA!#fRnA}each}tank • . <br /> I _ The San Joaquin Local Health District's Tracking Sheet will accompa y <br /> with its site identification number. The Tracking Sheet is to be returned to San <br /> al or <br /> Inr,.ann, <br /> onal Health District within 30 days of acceptance of the tank by dispos <br /> ecycling facility. ► ss..laer of uA <br /> } �'�h n�s''pr noted ►ploy Ia <br /> t �lble for <br /> . —:no that thin form 1a cMiated and returned._ <br /> ACILITY NAMi: / <br /> AGILITY ADDRESS! c s` [oTT� �rY/ �,/�. =p <br /> "d <br /> ANK LD 139- Y <br /> *fAAtAR#tR}R!RlRR}RAARAIRAftff#ttAAlfRAA#AtfR!!flttftt}f}#tt}} tf #AA!#ttRlfRlRf RftRlfltff <br /> gCIION - 2 - To be filled out by tank removal contractor: <br /> 'risk Removal Contractors <7:�7-ncKEnd <br /> l <br /> ZIP: djK U S-- <br /> ddresa t Phone#: ? — <br /> i <br /> 4''elephone: ( ) Date Tank Removed: <br /> RfA#t#ftlR}}Atlt#}tR*fflAAltA!}tf#}*R!*f*fftf}Rfftlf!*t}t!!!R**f RlR***f**R!*R!R**f*!*R*RRR <br /> fTa <br /> HON 3 -To be filled out by contractor "decontaminating tank": <br /> - � _ nuc <br /> �nr Decontamination" contractor: r i__ _ . s �y <br /> SS R L ,0. 4fp: y��-ms's- 1393 <br /> M Phone#: <br /> thorized representative of contractor certifies by signing below that the tank has been <br /> eeontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> *RAAARRRftRARftlAR!}tA}AfAAARR}ARAfR!}!!*f!f}}f!A}}A!*RARIR!**t*!}f}*}#RlAAAAAR!!!!R#}!A#! <br /> ®('PION t - To be filled oft and signed by an authorized represnetative of the treatment, <br /> 1totage, or disposal facility accepting tank. <br /> 'adlity Name <br /> date": Zip: <br /> Phonels <br /> - its Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> �� RRARAtfR}RRltt}A!}!AR}RRARft#f}*t*f RRf R!!*fRflff}1f!****tf!*!*f*}Af*#**A!f#f#*}ltARlt!*!f! <br /> 9 '23 019 12/8/ <br /> IAILINO INS'iRUCfIONS1 !UA IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> KJ p. O. BOX 2009 <br /> STocKTON, CA 95202 <br />