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0 <br />0 <br />SAN .7OAQLJIN LOCAL 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 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 <br />TANK ID 039- <br />*XXX***XXXX**X*ii*X*x******XX***X********xX***xX*X**x*XXX** <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Telephone: ( ) Date Tank Removed: <br />*************xX****X********x****X*******XXX***X************xXX**X************X*X******XXX* <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />frank Decontamination" Contractor: <br />Address: <br />ip: <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 />x*********xxX*it****Ytx*xX**x*'k*x*x*kXX**xx***XxXXXx*xxxXXX*xx**xxx**xx***x*x**xxxxxX*XX**xxx <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 <br />Address: <br />Date Tank Received: <br />Zip: <br />AUTHORIZED SIC24ATURE AND TITLE <br />************X******X***************XXX*******X*X******X**k***********************X*X**x*xX* <br />Ell 23 049 12/88 <br />.AILING 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 />