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SAN Jcf uI IV T ®CAL HEALf DI STRT CT <br /> UNDERGROUND TANK DISPOSITION TRACKING 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 Permit with number noted below._isresRgnsible for <br /> ensuring that_ this <br /> �form is completed and returned <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39_N <br /> - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: — Sc <br /> r- Sv r Tc` za- <br /> Address: . .�( V% -7-0 Zip: ±5--2,0 <br /> Phone#: ' -o <br /> Telephone: { i Q ) Gj - G Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ZLJC-S/G ,�1 �j/l G ✓ /�, _ <br /> Address: 7a S� � � ��2 r � �r CT�r � 47_2�A4aZip: `I�J.2a <br /> Phone#: <br /> Authorized 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 /> 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 dame <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />