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Vis_ L <br /> 0 ! OCT 1 c tQB� <br /> SAN 70AQUIN LOCAL H Ar•TH DIS=TIQP�NMENiALHEALTH <br /> PERW SERVICES <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> x*xxzxxxz**zxxxxzxxxx*xxxxzxxxxxxxzxxxx*xxxxxzxxzxxxxx*xxxx*xxxxxxx*zx**X*xXxXx**xxxx%xxx*x <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: COIF k nIt`lS(L C,o?-(oo2AT7 <br /> FACILITY ADDRESS: 400 vJ cs 1 .LP1 C_c) Te_c�r-Y C n <br /> TANK ID #39- - <br /> xzxxxxxxxxXxxxxxxxxxxxxXxxxxxxx*XxxxxxxxX*Xxx*x*xxx*xxxxx*Xxxx***xzxxxXxxXxxxx*xxxxxx**x*** <br /> SECTICN - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: QALTbr-Z t_:� Nc I fJE�121N� <br /> Address: ,6,721 fZ�SKV_ Zip: :?5691 <br /> W Sw�tD . cA Phone#: 916 - 373- 11"7 -7 <br /> Telephone: ( 91 to ) '3'l3 1177 Date Tank Removed: hove. �gEX- <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: hJA L a,.1 C N 4Iti S1 RA M � <br /> Address: P3rl Ke 1-X�Y^jtZ Zip: 'i5691 <br /> toss- r1aPhone#:(41ie ) 373 - 11-77 <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 C2ooS G7n0t - "Er.JT <br /> Address: 1 % 315 Zip: <br /> RoNCHo C 2PovA C_1 Phone#: (9g6) b3S- Lm8C5 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> x*xxxzxxx**xxxx***xxxxx*xxx**xxxx**xxx*xxxxxx*xxxxXxxxxx**xxx*x****%*x***xxzXxx**x*x**xxxx* <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: 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 /> =TON, CA 95202 • <br />