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921%LN A(at3IN LOCAL HEAL 17I1STRI('—T <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> RRARRRRRRRAA!*RRAAAAlA!*RRRARAARRARRR**RR*RRR*RRRRRR*RR**R*******RR*R*#*RfiRR#R**RfiR*R***R*R <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 bydisposal or <br /> recycling Facility. nims�r noted below is responsible for <br /> , nsurina that this fors is com"leted and returned \ / <br /> FACILITY NAM C 1T(_j C).',) C)L — <br /> FACILITY ADDRESS s <br /> TANK ID 139- - <br /> RRRRRRRRRRAARARRRARRRARR##*###R*##RRR###RRRR##*RR##RR**RRRRRRRRR*###*RRfiRfi#Rfi**#R**RR*RfiRRR <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> L �-� -L e- <br /> Tank Removal Contractor: ��T c�c �11-r�,fl �C f �/i c i- �t��1 Gti - <br /> Addreas: �c� LN �`ti k Ll,,� Zlp: <br /> ��TCt tUn CA Phone#: <br /> Telephone: ( oZ�( ) Ll (1- 3 .� Date Tank Removed: <br /> RRRRR*RA*ARRRRRRRRARRRRRRRfiRfifififi**R*R**#*fi**RRtRRRR*RRRRRRfifiRfiR**R***R**R*fiR*fiR*#***R***R*R <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: IC—S`�C N <br /> Address: �5=. �(�C C ��C Y zip* <br /> pct\�M C fl Phone <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 /> fiRRRRRAA#*#RRRARRRRRRRRRfiRRR*Rfi*##RfifiR#fifi#fi#RRRRfiRfi*Rfi*RRfiRfi**fifiRfifiRR****RRfi*RR*RfifFfiR**R*** <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 SIGNATURE AND TITLE <br /> RRRRRRRRRRR#RRAAAR*RRfiRRRRRRRRRRARRRRRRRRRRRRRRRR*RRR###*RRR*R*RR*RRR*****RRfi****fi*****RR*fi <br /> EH 23 049 12/08 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM., UNDERGROUND TANK PROGRAM <br /> P. 0. DOX 2009 <br /> STOC(TON, CA 95202 <br />