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J UL _2rWEJ1 1015 MOORE PETROLEW P <br /> S p.N J COAQI J I N IJOC.AT.. HMAL-TH D I S TR I CT <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. Tne holder o the cermit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: , r✓Z>+r�Je- 5 t 110 "U .may <br /> FACILITY ADDRESS: �y g U r2U. V FCrt. 2p. XrYUTkCr9 C,1 (1 336 <br /> TANK ID 139- <br /> SCG'TION - 2 - To be filled out by tank removal contracto <br /> Tank Removal Contractors <br /> Address: � ( t 7 /� ✓ Zip. ` <br /> 7 , <br /> Phone0.d G- o L <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor; <br /> Address: Zip: <br /> Phoney: <br /> Authorized representative of contractor certifies by signing below tNit the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLC <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 �._. <br /> Address: Zip: <br /> Phoney: <br /> Date Tank Received; <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EII 13 019 11/88 <br /> MAILING INSTRUCTIONS: ELD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCYTON, CA 95202 <br />