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SAN pA UIN I OCA - HEALaTI i I S'TR CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ct*s*Tracking*Sheet*will accompany each*tank <br /> SECTION 1 - The San Joaquin Local Health DistriSheet is to be returned to San <br /> affixed with its site identification number. The Tracking tank by <br /> Joaquin Local Health District within he dayscerm0 with accepntumber noted ance of ebelow is responsible for <br /> recycling facility. The holder of t <br /> ensuring, that this form is com leted and returned e=` <br /> FACILITY NAME: <br /> l S i vE.o.CT E-1 L(-N n3<-21i nt <br /> FACILITY ADDRESS: <br /> Fa 1 S hiT `:T` LPt KAP C�Ft 1 3 0 <br /> TANK ID #39--- <br /> SECTION <br /> 39-SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: E N1C'�� <br /> �3 l <br /> Address: 1 i}Pc'Fr', F b Zi <br /> Phone#: <br /> 2 ) �� _ Date Tank Removed: <br /> Telephone: f � <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Zip: y3 <br /> Address: Phone#: Cam <br /> Authorized representative of contractor certifies by signing below ti-kit the tank has been <br /> debe regulated by Department of Health Services. <br /> decontaminated in an approved manner as may ,/�,/A g <br /> SIGNATURE AND TITLE <br /> an*authorized*represnetative*of*the*treatment,** <br /> SECTION 4 - To be filled out and signed b,v <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> Date Tank Received: <br /> AjjTHORIZED SIGNATURE AND TITLE <br /> Elf 23 049 121$8 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ate; UNDMGROUND TANK PROGRAM <br /> p. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />