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S AN (AC2LJ I N LCC.AL, HE' .�rH D I S'I'R I CT <br /> L, c12GROUND TANK DISPOSITION TRAC,G RECORD <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. Me holder of the permit with t ow ' f <br /> or <br /> ensuring t this f <br /> FACILITY NAME: ktz--1 C-t-4\.j C7U e-1 lv to <br /> VA ym" <br /> FACILIT`l ADDRESS: 2.e)�Y~1 L -JA 7 EIZL-oo <br /> TANK ID 139-��j� MAR 15 19r?0 <br /> SECTIO[ - 2 - To be filled out by tank removal contractor: PERMIT/SE V;.CES <br /> Tank Removal Contractor: <br /> Address- 1�3Z ti t�1 t r' l �� ,�rZ� �'_ _._Zip: cf3 Z 7 4 <br /> Phone#: -L�o L2c� <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: _F1NF <br /> Address: -7 l2 SCSN 1 cf ��J�j• ` 'Lip: <br /> p: <br /> Phone#: oi8 <br /> Authoriaed representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> i <br /> SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> I Facility Name <br /> U� t <br /> Address: 1 � <br /> Zip.. <br /> Phone#: -So?3 ZZZv <br /> { Date Tank Received: <br /> AUTHORIZED SIGNATURE ANI? TITLE <br /> 91I 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br /> SAN JOA+QUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGP M <br /> P. O. BOX 2009 <br /> STOCKTCV, CA 95202 <br />