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SAN �AQUIN LOCAL �TH DI STF2I CT <br /> L,..aRGRWND TANK DISPOSITION TRACK..-C RECORD <br /> XYYt/tYxX#f%fiYlRtXYtXRttwtit RtixXYt't##t*tX*#Rtt*tiRit%tiXRt%XtX%Xttt*fi%*!t#X%tittt#R%R*t##f <br /> sDCTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tan) <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 nwnber noted below is responsible for <br /> ensuring that this form is completed and returned� <br /> FACILITY NAME: ��<< �0O`�`k101o <br /> FACILITY ADDRESS: �Z.S3-I �1 -EZ LA0 R� `J( c1r-y__TO(_J <br /> TANK ID 139- I ILD_ - o I Vl/ 00(7 <br /> XiRXYRYt*ttitR*#tX*Yltttt*ittXRt*%X*ttlYlf*Xt*RtYtttw XYYfi*Y***##***#%x%*%ttYwwX##%xXkXt%t# <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 2\ a`'F T 0L) rj .. <br /> Address: ��-32 Fi4 2JkFn1 �PrC£ � �� Zip: 93z� <br /> Phone 1: <br /> Telephone: ( ) Date Tank Removed: <br /> t!ltYtRRt***%x*w*Rt%txttwltwwxY Ywwfiwxt%%R%*%tRittlt**%t**t!*Rwtt XYwxlxfixx xixx*#fiR Rx RxRx#YYw <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 2r_f1Njb-2 _ !S�e�20 f' <br /> Address: _. .Q2soN l 'G . 53 3 Zip: <br /> Phone 1: �G• 8 �r a <br /> Authorised representative of contractor certifies by signing below that the tank has been <br /> i <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> i <br /> i <br /> SIGNATURE AND TITLE <br /> i *Rtt*Xt**t*t**t*%twt*t#tt*t*t#*XYtXt#%*!t*Rttttttttt*!w*t*wwx*****wRtX#xfitwtlfittt*#**tt R#*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 Name oVv ��i Kly� P'N K-' 1 I <br /> Address: I fJ SS �. Z� O Lp_• 2,x 0 zip: <br /> phone#'201-(0"13 - 27,Zt <br /> Date Tank Received: <br /> I� <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ###fixRXz.:rRz.x*xt**zez�**tztr*#*t*tr#XtXt*tRt*t*itttt*tt*Yx*Xt*wttt#tx#t##*iw:it%t#xt*tt*x#t+ <br /> Ell 23 019 11/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT "� <br /> ATM: UNDERGROUND TANK PROGRAM RE W <br /> P. 0. BOX 2009 JUN 1 2 f"^� <br /> STOCKTON, CA 95202 <br /> :NVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />