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SAN JAQUIN LOrpT• pT•TH DISTRICT <br /> I <br /> U#. GROUND TANK DISPOSITION TRACR�REOORD <br /> x:xzzx:zzxxxzxxxxxxxxxzzxxxxxxzzxxxxxxxx:zxxxzxxzxzzxxzxxxxxxxzxxzxz:xxxxxxxxxxxxzzxxxzxxxx <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`f <br /> orm is complpted and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: Zs3�1 u0A-%-FZLoo 9-0 S( c> - 7-5 -J <br /> TANK ID 139- - 0Z <br /> xzxxxxxzzxxxxzxxzxxxxxxxzxxxzxxxxxzzxx`{#xxxxx�zxxkzxzzxxxzxxxxxxxxxzxxxxxxxxzzxxzxxzxzzxzxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: `�-3? X74 �2J�F�n1 \ y PIZ£ r �• Zip: cf3 Z7 <br /> Phone 1: 2Z�-i.8tvl.2jc)4 <br /> Telephone: ('2� ) (08� 0203 Date Tank Removed: �1�lgh <br /> xzzxxxxxxxxzxzzxzxxxzzxxxxzxzx:zzxxxzxzzxxzzxxxxxzzxzzzzxxxzxxxxzxzxzxzxxxxxx:xxxxxxxxxzzzz <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Y_FiN F� =S _ Ovl L Lr <br /> I - <br /> Address: � . I l� I —�2ScN �� ..cl 533. <br /> Zip: <br /> Phone#: bc�- 97q - <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated An an approved manner as may be regulated by Department of Health Services. <br /> L 8 - G7 / R `JCFC Dc /Q <br /> SIGNATURE MD TITLE <br /> zxxxxxxzzxxxzxzxxxzxxxxxxxxxxxzxxzzzx,tzxxzxzxxzzzzxzzzzxxxxzxzxzzzxzxxzzzxxzzxxxxxxxxxzzxzx <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility <br /> �accepting tank. <br /> Facility Name1 W K-- r I r <br /> Address: 1 4E5 ss 1D. 2� MA�FP 0 Zip: 93(03`7 <br /> Phone#:-2c;�i-(o?3 - ZZZo <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> zxxzxxxzxzzzzzzxzzxxxxxxxxzxxxxxxzxx:xxxxzxxxxzxxxxzzxzxxzxzz*zz:xxxxxxxxxxxxxx:xxzzxxzzxxx <br /> Sit 23 019 12188 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br /> '( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> _ P. 0. BOX 2009 <br /> r�rJ'r I n ��IFSTOCK", CA 95202 <br />