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SAN .7OAQUI1111 LOCAr. HEALTH DISTRICT <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 Loral 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: 9yI <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by/ tank removal contractor: <br /> Tank Removal Contractor: TL+c/c tz rel?-11,166 _(�TlO,,J <br /> Address: A41, aL1e;j,,d -27— <br /> zip: <br /> To -rrJ ,J Phone#: L � <br /> Telephone: (,-G`/ )_ -4/? K-?3Z337 Date Tank Removed- <br /> SECTION <br /> emoved:SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: e- Pt1Ck_ �_ OrV =_AIC. <br /> Address: � .5� pr( r1` El V!1 Zip: <br /> --F l C A Y1"O" n - CA- Phone#: 4//S 2 B�Wff <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********************x****xx**x****W*xx*********xx****xkx***x***x*xx*****x*xx*********** <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 _ Ck,�, \ <br /> Address: 3Lvo Zip: <br /> � ��mollrl C /a Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EI! 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 />