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32uWOAQLJIN r oczL . i*Ax.TH DIsa-aiCT <br /> l.:"cI2GROUND TANK DISPOSITION TRACK-_.,G RECORD <br /> Rtxxftfxtt*twr*R*fir*ttrt*ttttwfif RiRtf**r!*tfitrlftrlRx*f RXtlXfifxRtRRtttttfiRf RRffwfwf txfi** <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each t <br /> affixed with its site identification number. The Tracking Sheet is to be returned to S <br /> Joaquin Local Health District within JO days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted 12ttlow is resoonsible to <br /> ensuring that this`f <br /> orm 15 completed and returned, <br /> FACILITY NAME: t-142-1e-et'� LX::)`t to b <br /> FACILITY ADDRESS: Zs5a7 L1Ar-kEZL_CQ R-O "Tor_l <br /> TANK ID 139- _ _- �3 1p-oco <br /> xtfitrRRxrrfi rrzrRrRRxzttzwxffi XfixlRR tzR!lzfi�tztfi*fixR X*xz XXXRtfifitz Rf x*RXwfifilrtfix XXt X RrXfi*fiR <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 21 �`F _T (}onNS�. <br /> Address: I LIZ �A �2�1���n1 1 .i �P�2E , ` � p: 3 7 <br /> - zi � Z <br /> Phone1: 2p:77_(, („ <br /> Telephone: ( ) Date Tank Removed: <br /> trrlRR*RRf RRxXRtltfi XRwR*r.ltR XfirfiwR*ttXfi RRRlrxf Rxtx!*XRRtfiRr■RRttfiwRfi RtXxXR***fi RRXXRfw*fir1 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank^: <br /> i Tank Decontamination^ Contractor: r.f11-1 <br /> Address: C� . 11-7 1 i� a2SoN d . cl 53�_ 3. " ^ o <br /> Zip: <br /> Phone#: X0. 8 <br /> Authorized representative of contractor certifies by signing below that the tanJ( has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services <br /> i <br /> i <br /> I <br /> SIGNATURE AND TITLE <br /> tRtftRwfRRfxxRfx*wrrrx*trwxttw*tlRxrXxRRRtrrttfifttwxrt*ffxxxxrxttxfixxfixxRxwtfitxRftxtxXwtt <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> iVv Edi�I�Iv y_- <br /> Facility Namel A-N <br /> Address: I SS 2 <br /> � zip: <br /> PhoneY:�¢j-�73 - 2ZG <br /> Date Tank Received:- <br /> 17 <br /> AUTHORIZED SIGNATURE AND TITLE <br /> w*ttfRr*tflxxftt!*wRflttttrwt*rtttxfRlttfRrRwtt*lxtrfttxxxfixtt*CRRRRwXw*t*rtwtwxttxfiltxtxr <br /> Elf 23 019 12/88 <br /> NAILING INSTRUCTIONS: FOIA IN HALF AND STAPLE. ANFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOLXTDN, CA 95202 <br />