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• <br /> �1 SAN j OAQT j I NL pr�a r. HEAL'T`H IX E S'rF Z I CT <br /> / UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> r' <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 rmit with number noted below is responsible for <br /> ensuring that this form-is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID #39- 1 5 - <br /> *�**�**ire*�**>t*��******�r�xr*********isir*�r�r:�*�r�r*�c�*�*�r�rc*��r�**���***at*�r*�*���*�c���r*�*�r***�*��c* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: _-- <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 /> k'*'k******fk�YYc*7krk�ik*is*fir*�'�k*1k**'kYc**i��Yir**ic*fit**��'�c�l'***kit'k***k**i;i**�Cic*ir*ic*�Clc'k#:k**�r�t�c***ic*iririt*Yr7�k <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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AWHORIZED SIGNATURE AND TITLE <br /> Elf 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AI'I'IX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> ATTN: UNDEMGROUND TANK PROGRAM <br /> P. o. BOX 2009 <br /> STOQ{TON, CA 95202 <br />