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SAN 7QLJIN LOCAL. Hi~-aT •TH DISTRICT <br /> f <br /> L GROUND TANK DISPOSITION TRACK#RECORD <br /> *tX*x*txtlxlxxYx*x*x*lxXtx**xtxtltY*x**xtxlxX*!t!!!xx*x***tx*x*x*tXtx*!slYtXttx*!xlXxX*tilt <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 t f <br /> FACILITY NAME: 1cc> <br /> FACILITY ADDRESS: k-�� <br /> TANK ID l39- U �- <br /> xtx*itX7ttlxtix**X*xx!*tX*t****YtxxYt x**X* *Xx*t!x***Yx*x*xxx*Y*Y*Y**xX***ttlx!!!xx***ttlX* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: l 2� � �S (�o N Sl <br /> Address: 1�-3� 12\-)k<<n1 Zip: 3 Z7 <br /> n Phhone8: lzci-V 2tvi.2D9 <br /> Telephone: ( _) > Date Tank Removed: 3 I U <br /> Ytt*xX*Xxttxx**t*x**x***x*xt*t!*****Yxx*t*t*x**x*!xx*ltXttxxXXX **xYtx*txX***x*t*xltXxx*x*t <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: r_flNF1z �S _ �F�ilt � <br /> Address: O . I l� I 1� --�2soN ��..�1 533 zic: <br /> Phone#: �o. <br /> Authorised representative of contractor certifies by signing below that the tank has been <br /> decontaminatpd i an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> *lx:Yxxx!*xXx*xxXYtxtXxx*stxlxx*x!x!x*stlr*xx*xxtlt!!Y*x*xxxx*xxxtxxxx*xxtts*xx*tXxx!*x*t*t <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name1 ec,-rr v l K' <br /> Address: 1 `1�5 SS 12. 25� UA70a'X I 9-3(,0;v-7 C+/� Zip: <br /> Phone -(g-7'2j - 2-2Zo <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ****!x*xxt**tY*Yt*!x!x*!Y*xxx*xtt!!X!*lXXt**X*Yx!!!*t**Xxx*!t***Y*Yt**t!tlXxlt*!Y*X*!*!!!!! <br /> SH 23 019 12188 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> N(� OT'r �� P. 0. BOX 2009 <br /> l <br /> am- <br /> a- cs� �o STOCK", CA 95202 <br /> 1-5 � <br /> A8,)5 fq, <br />