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SAN JOAQLJIN LOCAL HFnr.TH DISTF2ICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *****x***********Xx*X*****x*******x*x***x*x********X***X*x*XXX**X***X*x*******X*X**X******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 nunLber <br /> ensur� ing that this form is completed and returned, °td below i responsible for <br /> FACILITY NAME: <br /> FACILITY ADDRESS: < < <br /> TANK ID #39- <br /> x**x*x***x***x***X***x**x*x**********xx*x*xa*********x*******x*x*****x***x**x*x**********x* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor <br /> Address: <br /> Zip: <br /> Phone#: <br /> Telephone: ( ) Gate Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has in an approved manner as may be regulated by Department of Health Services. <br /> i <br /> *x****xx***rl***x*x***********x******x**GN*xTUx*x*xDx*x�**x**x*x********x****x**xx****X***x** <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 <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> ***x*******x*****xXxX**x*x*****AUTHORIZED <br /> ***SIGNATURE <br /> *AND <br /> *xXz�******x****x*****x*****X***x*x** <br /> Ell 23 099 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 /> STOCKTON, CA 95202 <br />