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0 <br />SAN ao.AQUI N L,c)�s I F_A2 aTH is2 S7'1:ZY c7r <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 com feted and returned. <br />FACILITY NA?vE: C`' <br />FACILITY ADDRESS: y, <i 4, 6-- PI N, r; <br />TANK ID #39-- C <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: f.• <br />Address:,c} 3 i ���' ,� L �- r --r 7.� _ll�=; t C i Zip: <br />Phone # . <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: ".;A -"i ( %� ,A-V , 4 � -()e- <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 />**'skit*********k**it**�k**tkk�r***it***�t�c*4r**ic*****Yc�C*i�*'k*9k*�rx**i�*:l•:tY�ic**�k*�k;�*'kstit*ic#**sk*Yrir�t**yk�kir�r*it <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: <br />Date Tank Received: <br />_-_Z ip : <br />hone#: <br />A{IHORIZED SIGNATURE AND TITLE �- <br />Ell 23 049 12/88 <br />14AILING INSTRUCTIONS: FbLD IN fine AND STAPLE. AFFIX PROM'. i'OSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />S"t3cCTON, C:A 95202 <br />