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_N 704kJSN 'LOC"AT • HEP,1�T• DS S.TRI CT <br /> J' <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: MRS. MASUDA <br /> FACILITY ADDRESS: 288 EAST cTm RTRRRT . FRRNCFl CAMP, rA <br /> TANK ID #39- 2Y28 - _ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: WESTERN METER SERVICE, INC. <br /> Address: 2735 TRRPF.F. nRTVF. Ri1TTp. F., gTC)rKTnN, CA Zip: gS90F <br /> Phone# :( 2nQ) ada_tii ;,a <br /> Telephone: (209, ) 6✓r2 Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank_Decontamination"�".ORtractox:---WESTERN METERE SERVICE . INC. <br /> Address: 2735 TEEPEE DRIVE, SUITE E, STOCKTON, CA Zip: 95205 <br /> Phone# : 21� 9r/g=S/2y <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 SIGNA`T'URE AND TITLE <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A'ITN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />