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SAN J AQUI N I pCDC ,I HF'A. rrH DZ STR I C7' <br /> C+..- c�ZGROUND TANK DISPOSITION TRAC 4 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. n2e holder of QX hermit with number ogted below i - responsible for <br /> ensWging t thig <br /> `f <br /> FACILITY NAM?: 1 -IL DOS Lv Lo <br /> FACILITY ADDRESS: � �� ��_�p0 �J� �C_�L=M13 <br /> TANK ID 039- I C�p v�L <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: (2—k _ �L) N S t <br /> Address: ��—� - 2�1��.�1G <br /> - l t: ��-2-£ .Zip: c <br /> Phone#: <br /> Telephone: ( ? Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: r`-Fj h1 r)z _ !Se�'v l C-& <br /> Address: 4 �� f =2 Sc�N f� � Zip• <br /> i Phone 0: <br /> Authorimed 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 /> S I GNATURE 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 /> Facility Name <br /> � A -,j Y- <br /> Address: kl] Z i p: '75 G'3 r` <br /> Phone#:-21J1-fie 3 2_ZZt7 <br /> Date Tank Received: c <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ***�******t*#:r**�e�x�*�►�*�t��t�r*,r*x****��**�****��s*��***�*��t�#***�tttx*t*�***�t�t��at*�t**��:*x*x*� <br /> Sir 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND S'T'APLE. ASFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />