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` " L' N 1 OCfi� F3�.AI�TII T'TSTRSC'i' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD ' <br /> -- <br /> SECrION 1 - The San Joaquin Local Health District's Tracking sheet will accompany each <br /> afication number. The Tracking Sheet is to be returned to San <br /> ffixed"with its site identi <br /> Or <br /> Joaquin Local .Health District within 30 days of acceptance of the tank by dPGaible for <br /> recyclinq facility. The holder gf the permit with number note4 below is r <br /> '.censuring that this form is completed and returned. <br /> 'FACILITY NAME: G?! S E U <br /> FACILITY ADDRESS: S. J, nf�7--z> <br /> I UO G c,O�Q <br /> TA:"IK ID 939_ 19�./�-1�---- Ai <br /> `SECT?ON - 2 - To be filled out by tank removal contractor: <br /> 'Y i2ava1 Contractor: w/ r t N �nzrr <br /> Zip: <br /> address: o ✓ Phone#: � `✓� '; r%•`� <br /> Telephone:' ( ) _Date Tank Removed: <br /> ' SECTION'3' �-To be filled out by contractor "decontaminating tank" : <br /> o <br /> 'Tank Decontamination Contractor: <br /> A.-Id-res;-s. /'9�J� 4oan ! r - , : r Phone#: 42 ^ <br /> i <br /> «uthorized 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 /> S,LMjON 4 -.To be filled out and signed by an authorized represnetative of the treatment, <br /> storage; or disposal facility accepting tank. <br /> racility Name <br /> zip: <br /> Address: Phone#: <br /> ;ate Tank Received: <br /> AUTHORIZED SIGZJATURE AND TITLE <br /> EH 23 049 12/88 <br /> 1-,RILING INS'1RUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AT'PN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKmN,, CA 95202 <br />