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:7 <br />S AN J C)AQU I N L C]C'ALj HEAL rrH 17 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. The holder of the permit with number noted below is_res onsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: �' A 4_`�i?L' ` -.f-- „ <br />FACILITY ADDRESS:��; i� --�� L _�� Z 0 L?1_e L - - <br />TANK ID #39- _- /�G <br />SECTION - 2 - To be filled out by tank removal contractor:. <br />Tank Removal Contractor: - - <br />Address: ,f .21i r ' Gt. Lam' b C CA- <br />Telephone: ( j Date Tank Removed: <br />SEC'T'ION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />Zip: <br />Phone#: <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 />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 />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Elf 23 049 12/$8 <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 />STOCCTON, CA 95202 <br />