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SAN C0AQ1LJ3:N LQC,AL, "'AL,THUNDMAIND DISTRICT <br /> TAMC DISPOSITION TRAAcKING R D <br /> •s**s�***��:��*�*�***t�:**�**��#�*******�r���t:�****�r�t*��t���s*s�**ire**�*�*�*********#�**"���** <br /> SECTION 1 - The San Joaquin 'Local Health District's Tracking Sheet will acc <br /> affixed with its site identification number, The Tracking Sheet is to be rrnedato San <br /> Joaquin Local Health District within 30 days, of acne <br /> recycling facility. Pince of the tank by disposal or <br /> eMurlIl�that this •form 1. c n7 ntwl �r,aOW i <br /> FACILITY NAME: s <br /> FACILITY ADDRESS: j ri / <br /> TANK ID #39- 2 :-M? _ D <br /> SECTION - 2 To be filled out by tank reel contractor: <br /> Tank Removal Contractor: S <br /> Address: <br /> a C-4 P4- zip; ys3SL <br /> _ Phone1: <br /> Telephone: QL� Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: LAJ. �c -- <br /> Phone#: � 3 <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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name e_4 <br /> Address; W ArA--Mk ^OAFS <br /> 10 Zip; 5ts7a��. <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EN 23 049 12/88 ******** ** <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROD M <br /> P• o. Bax 2009 <br /> STOCKTON, CA 95202 <br />