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0 <br /> SAN a0AQ1LJI N L.00AL. FMAT•TH DI S=1 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 is rgpponsible for <br /> ensuring that this form is completed and returned.- <br /> FACILITY NAME: R <br /> FACI LI TY ADDRESS: / f /a F_ 122 E t L -57`"©r-L f-2 <br /> TANK ID #39- -2 - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: i`J, I� d r� i'I cJ ;'� 1�/S c /1 � s Zip: <br /> �f <br /> 3'S 7 5, 5f . 1 l Phone#. <br /> Telephone: { ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: r Ir ., p l� s 74, <br /> Address: E-01 `� I t`l r1 �✓ -- -,; Zip: w ) i <br /> Phone#: f <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 /> S I(MATURE AND TITLE <br /> ********#**ick#:khk**Ye***#*�F*�F*�r**irxc**•k********Yc#*#!t*�k**#**#*:k*#*********tt**#**it*#ir*ilr##*#fir*9:* <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 f C, (5 <br /> Address: '7 , `f t E' r� �� CL ��? fi Zip: <br /> Phone#: r29 i -ra <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Err 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERCROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> ST )CKTON, CA 95202 <br />