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n SAN .TOAQUIN LC3C�,AL HE,AI�TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECDRD <br /> SECTI0N I - 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 gesp s• le for <br /> t this form ip completed a returned, <br /> FACILITY NAME: � � f V IS cz C_ ci=n t e_,; 4c) ` t� <br /> FACILITY ADDRESS: ,5—_5 "? - GLC C_O-Zll e7 l o Sl- . 4adr <br /> TANK ID #39- 3 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: e_Y <br /> Address: 7 ( 0 �,2 Zip: <br /> L r 4 Phone#: - <br /> Telephone: (._Le ) - I - f Date Tank Removed: <br /> SECI"ION 3 -To be filled out by contractor "decontaminating tank": <br /> ] f <br /> Tank. Decontamination" Contractor: <br /> Address: o !1 vac r-e — <br /> �� � _.. .,� Z <br /> ..,- ip <br /> Phane# <br /> AFI c• C fl � o rq� �7 r t � � `�=---`� � <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 /> ****ylr*'R*k******tic*****�k*********tk*****yk�ItY�**#***yk*Jr*:k•k*yr****i�************W****ir************* <br /> S=10N 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, ar disposal facility accepting tank. <br /> Facility Name t-1A i_r\C >1-jC1� <br /> Address: ? C car s n <br /> �-• � Zip: 57AII e 7 <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E!! 23 049 12188 <br /> I to I LI NG I NSTRUCTI ONS: FOLD IN HALF AND STAPLE. AFFIX PROVEN POSTAGE. <br /> SAN JOAQUIN LOCAL IMALTH DISTRICT <br /> AWN: UNDMGROUND TANK PROGRAM <br /> P. 0, BOX 2009 <br /> S`V KTON, CA 95202 <br />