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SAN 'jOAQLJIN LL <br /> OCA . DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RSD <br /> XrION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The <br /> tckingnce ofSheet <br /> tank is tobbe returnedoto San <br /> Joaquin Local Health District within 30 days of P <br /> isposa <br /> recycling facility. _The holder of th hermit with number noted below i5 res onsib a for <br /> e s t f m s m t a <br /> FACILITY NAME: 15(�l� SAVE e.I'TN i2 �'� (cL�N •� <br /> FACILITY ADDRESS• I S �t1c lT T' IYRTKUD P C A% q S_53 d <br /> TANK ID #39- - <br /> *x*xx*xxx*xxx**x*xxxx**xxxxx***xx**x*x*�rxxx**x*x*x*xx****xxx*xx*****x****x*xxxxxx****xx** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Se ral QQ <br /> �- l t,T P�cTC Z i : <br /> Address: Phone#: <br /> �,� t„ <br /> Telephone: (�.4�I .) � �y�— <br /> Date Tank Removed: <br /> x*x**xxxx**x*xxxx*x*xxxx*xx****xxxx******xx***xx***x******xxx*xx*x**xxxx**xxx*x****x*x**xxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: SENL <br /> � �� <br /> Address: 4Phone#ZiCO�� <br /> e tank <br /> Authorized trepresentativediapov d mmaannertor as maytbeies by regulatedning below by DepartmenttofhHealth Serves. <br /> en <br /> decontaminated i pp <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 L EY1hT A <br /> Zip. <br /> Address: L <br /> Phone#: 415 t,�C <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E1! 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> p.'l'TN: UNDMGROUND TANK <br /> PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />