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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> * * * * * '4 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: q5i I ,WIW50t1 W.&Y)0f0,K0& TANK ID #39-/208- <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone # <br /> Zip <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination'" Contractor 29,/ E/ 1 Uvr� 2 Vic� <br /> Address 0 r - Phone#.805-3i3^,E770 <br /> 'f/lu5 -i �/� C�/> _Z ip__s' <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> 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 <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. <br /> Facility Name <br /> Address Phone# <br /> Zip - <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> MAILING INSTRUCTIONS: Fold in half and staple._-Affix .proper-postage. <br /> -- —�--�- --- --�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P.Q. BOX 2009 <br /> STOCKTON, CA 95201 <br /> .ea —M T77 , <br /> " 'atk'S``' _ - <br />