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SAN �AQLJIN LOCALTH DI STS�I CT <br /> cRGROUND TANK DISPOSITION TRACI=• G RECORD <br /> fii*f Yii**ttf X*Xftixt*Xt*Xtf itiY*xt#tflttt}txR1Rf*ix}R*Rit*iRXtXYf*t}tXRYYRt;lRxtf;lY*fifi RtYf <br /> SECTION 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 facilit1y.\ The holder of tha permit with number noted below is re5consible for <br /> and returnita, <br /> FACILITY NAHE: <br /> FACILITY ADDRESS: Z�3� IUF,1LL00 `Jl � -�TO-r_j <br /> TANK ID 139- I"1 7 - O2 �00 Jll l <br /> ' ttfx*lxxtz*t:**fiX*Rf RRtXf Ytx*f xtxRf R! *lItXXRxR ;Y fi*Rfifiixxkfifi**x!Y*x*fiYx*ttff;Rfitx*YxttRA <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Zip: <br /> Address: `Z32 FH 2�J�F�n1 l J � l' Ir, �I3Z7 <br /> Phone# : 70rj-L•'F4o-<-ti <br /> Telephone: ( ) Date Tank Removed: <br /> i YtXXtRRXtRxt**t*};tR}ffifiR/f itf Rk t*XxltRtxRt*RR*#RtR;;tRX*;lffxx*i RRx RfiRtfii*f fixxt Yxfifitx*fil <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ��L Y F1 N F " I f S �F1CJt L L <br /> .i <br /> Address: •O . I I� I �2soN 4. 533. zip: <br /> Phone#: arc;• E - <br /> I <br /> Authorized 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 /> t*tYt;}Y}};1titR;*t;}ttRxRRtt*X!x*ttxxfiXttf tttxxRRtliii*x!*tXkxxYXX*xfix YRx Yt22xxxYxlSxAxX <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility �accepting tank. <br /> W 1 Kl u l P.t�i <br /> Facility Name_ Y— <br /> Address: I SS 2D 2 M + Zip: <br /> Phone : 201-1o'n <br /> Date Tank Received: ` <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *tRR;R*tfi*!Rt*tiff;};}Rt}}}t!!RltlRltltR;f Rf1tRRRRl;*i*x*}R1Rtlt!*#*t****;Rt*t**!fi!*ttYlR <br /> BY 23 019 12/88 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ABFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AM: UNDERGROUND TAN'S( PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />