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STI JOA�v2N LOrnr• HEAT Wrq DISTnjCT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 ti_ he Dermi with n -I- - .ensuring that this form is omDleted and returned, d below is reams sibl c <br /> or <br /> FACILITY NAME: 'I.P1N — IIiGein( r -Oti1PFl <br /> FACILITY ADDRESS:9gon trn �v� o <br /> ti r1/97� �n/9 <br /> TANK ID #39- __ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: l <br /> Address: 12 <br /> Zip 7 - <br /> Phone#: q Z ` <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor <br /> *k**#kftdec" ontaminating tank": <br /> Tank Decontamination" Contractor: ��✓ b'CC <br /> // l <br /> Address: Doi/ }fJ�Cy/ /� 1 / u <br /> -'�--------� �n i � 7 Zip: a <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the <br /> decontaminated in an approved manner as may be regulated by Department of Hetank has been <br /> alth Services. <br /> bIUNAWRE AND TITLE <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facl ity accepting riw <br /> Facility Name <br /> d - <br /> Address: 7 S Z S t� ` Vic VP <br /> Zip: 9s_E-Z 3 <br /> C Phone#: - - <br /> Date Tank Received: Q /C 7 90 9 <br /> lee 1'P$ <br /> k*********k#*********kk*#k*k#***THORIZED**k**�fifi***'k***D****T*X <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. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />