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( , . SAN J •S2LJIN <br />LOCAL. r-rF:p.r• D2STRICLT-;, ,�, <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />xxxxtxxxxxxxxxxxxxxxxxxxxxxxxtxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxtxic**t't ilje tY�tti�i�tl� <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 />ensuringthat this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39- - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Zip " <br />Phone#: <br />Telephone: ( ) Date Tank Removed: <br />*************X*****XX****X*X*x*****kx*******x*****x*******k**kX*****************k******x**t <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: Zip: <br />Phone#: <br />Authorized representative of contractor certifies by signing below tlkit 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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name I_ ; - - <br />Address: Zip: <br />Phone# : zl i <br />Date Tank Recei <br />AWHORIZED SICNATURE AND TITLE <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL {EALTH DISTRICT <br />AM' UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />