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{ s lu"T JUS LJ , <br /> Q I N LO�,AL HEA,L,'I H DZ STEZI CT <br /> UNDERGROUND 'TANK DISPOSITION TRACKING RECORD <br /> SDGTION 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 pqrmit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: 4--" `-t) t-{l lA <br /> FACILITY ADDRESS: -77S u3F;ZM: 'i��� �� � <br /> TANK ID #39- 4h ( - 2 C>v _. n. �e,,- iL <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: �rJ <br /> Address: 3 l oo-ES-1 rq Zip: <br /> A E t - Phone#: <br /> Telephone: (2-0914-—q.� _ Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Sf`�'lei <br /> Address 3 y Zip: <br /> Mtn,6 rz <br /> c`�i ',� �3 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 /> EH 23 049 12/88 <br /> MAILING INSTRUC'T'IONS: 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 />