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SAN OAQUI N I<.00AL� KP_AI,TH DIS-1 ICT <br /> U.. &GROUND TANK DISPOSITION TRA .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. The holder of the Dermit with number not bel,)w is responsible for <br /> eaguling t this f and retyrned. <br /> FACILITY NAME'_ IL-1 L `C <br /> FACILITY ADDRESS: <br /> G <br /> TANK ID #39- � n �,(�'700 f 1- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: t rj S <br /> Address: 1232- ,,2L�;FUt� �.�-rZ� -. zip: 3 Z� <br /> Phone 8: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: z-F_fi1-1l L L <br /> Address: �� 1 1 t ,2 So N C . C1' S 3 j• <br /> I Zig: _ <br /> Phone#: <br /> Authori3ed representative of contractor certifies by sinning below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Wealth 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 /> Facility Name , <br /> Address: ?.;) ,;Is � 2 1�l " zip: `�3�3� <br /> � <br /> Phone#: - Zz <br /> E <br /> Date Tanis Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Sit 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQU I N f.O(.AL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANS( PROMM <br /> P. 0. BOX 2009 <br /> STOC)(TON, CA 95202 <br />