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SAN .70AOUIDJ LOCAL HEALTH OT STE2I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> w*********w***W**w*****W*W*****w*****WW************W****W**w*******W******wWW*W*WW***W***Ww <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 and returned <br /> FACILITY NAME: <br /> FACILITY ADDRESS: �I �Sc�O N <br /> TANK ID q39- <br /> ***W*W***W*****WwW***W*W*****W******W*******wWW**W*WW****W*W****W******W**WWW*W**********W* <br /> SECTION - 2 - To be filled out bytank removal contractor: <br /> Tank Removal Contractor: S7-ye //c"to S'evzylce _"--�T/O,,J A-4, <br /> Address: =<ak� •�I -�T- Z1P: <br /> TO iv Phone#: L 6 <br /> Telephone: (,1269 J 'y6 y ?X715 Date Tank Removed: <br /> w********Www*W*W**W**w*WW*WWWWW***WWW*W***W*www**W****W**W*W*****W**WW**Ww*********WWW*WWW* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: E Pk�CI�O N =,At C_ <br /> Address: pp" rr E 10 Zip: <br /> RIc 'tYri0nf) Phone#:y�S23S—/3 <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 /> **W*W**w****WW***wWWW*W*WW*w**W*W***WWWWWW*WWW*WW**WWWW*WW*W**WW*W*WW*WWW*W*WW*WWW*****WW*W <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 IGC tC�,SoJ\ <br /> Address: v2� s p r IJZ Y� Zip: <br /> hflrl C /a Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *WWW********W*w****W*w**wW******WW**W**W*WWW**WW*Ww**WWW*W*WWWW**W*WW**WWW*WwWWW**WWWWWW*** <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> j , SAN JOAQUIN LOCAL HEALTH DIS'1RIC1' <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />