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` SAN JOAQ�N LOC"-.2_jI. f�•n.r .�•I.I�ISTRIC'I' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *!**!tY#Y#Y!YltYltYYtitl3lY3lY!*!Y3lXitlf 3Yx3!*lXft]tYYlfXlf Yf YYxXxit!*!!X!*!t*!!*!ti!*f YfYx* - <br /> SECTICN 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. rp The hoof the permit W�*h numhPr . <br /> ensuring hat this fOis rn leted and et racoted teloV tG pp le fnr athr <br /> FACILITY NAM (-ifu . Of Es�a/on t�OippYd�(m YP�/ <br /> FACILITY ADDRESS: v?l03 Lgin ESrcllM fin, %5-3?0 <br /> TANK ID #39h0,-Zj Ave <br /> .fRltXx!*!YtlXXfXtxx'Xx':t:tYYYYXlXxltixlttY *!*!*X*tlYitlYiixi*!f Y! *X!Y!*ttlX':tXYl3fYXXf***!x!# <br /> SECTION - 2 - To be filled out by tank removal contractor.- <br /> Tank <br /> ontractor:Tank Removal Contractor �I L , pti,Py <br /> Address: i'> I nAu4f <br /> Phone#: <br /> Telephone: <br /> lxxxxxxlxi:ixxxxxxxxxxtxxxxxxxxxxxxxxxxxxDato Tank Remm*vxedxxxxxxxxxxxxxxxxzxxx*xxxxxxx*lxxxi <br /> SECTION 3�-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Refineries Service <br /> Address': 13331 N.Hwy 33 P.O.Box 1171 Patterson CA., <br /> 95363 <br /> 67,4i_ <br /> decontaminated in an approved manner a <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> y be regulated by Department of Health Services. <br /> XYlxXXYxxzzzzlx Y!#YYx*Yz! tfxxxtxxxxGNfxxTUtlRE*xAN*xD*zxxxE!!x!z!lxxlXlzltxX!!!x!**fY!!llxxxixx <br /> SECTION 9 - T filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> fxxx*xxtlxxYixzxlt*zxlx*xlt3xxzxUiZzO*zxRDxxxXGNxxxTxRExANDxx*xlxZxxxxxxxx!**zxxzx*x*X**xxz-xxxlx <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 /> STOO(TCN, CA 95202 <br />