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• S.z1N JOAQ�N LOCAL HEALTH � STRI 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. The holder of the permit with number noted below is responsible for <br /> ensuring that this form is completed <br /> completed and returned. <br /> FACILITY NAME: TIl" \ J IZOCA 1— , ))#-(c . <br /> FACILITY ADDRESS: �3 2 I�✓ <br /> TANK ID #39- /i7 I - -2— <br /> ******W***W**WWWWWWW*WWxW***********************x******x****xW**W**W*x**W****xWWx*****x*x** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: WE- 5 ea y i; //V- <br /> Address: J1 Ql ✓, !�7-dc%77y1t/ . 4:4 Zip: <br /> Phone#: <br /> Telephone: ()-Qq Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: jAJA/� <br /> Address: 273 T����G �Ql✓tom 5'TO�/�'TDN G� Zip: S� OSS <br /> P one#: �2oa11 G,c1O�li�� <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 /> *********WWx*W****xx**x**x**WWWW*xW*xW**x***W**W***WW*x**W**WWxWWWW*xWx*W*Wx****x*****x*xxx <br /> SECTION 9 - 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 /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 099 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 />