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SP1 �DA.QUT N LOCAL. f-�F'�T�TH DI �T� I CT <br />UNDERGROUND TAMC DISPOSITION TRACKING REOORD <br />SECTION Z - 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 p2rmit with number noted below is resraonsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: f `S �'�'F: pR lk" o -r• - <br />FACILITY ADDRESS:.f J fa 7 /Yl4ly7-4,0V P,__4 ii - TAI <br />.a..�i <br />TAMC ID 039- /d - <br />SECTION - 2 - To be killed out by tank removal contractor: <br />Tank Removal Contractor: c F c� Fie 1r <br />Address: , C. /�Gx ? 7 cA r. C__ <br />-- -•--. Zip. <br />Phone# : <br />Telephone: (,2oc? ?OK)Q Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address:log/Zip: � v <br />Phare# : U/,j_ _ oo n <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 />- SIGNA AND TITLE <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 <br />Address: <br />3—Zip: �'' -�A--�1 Z <br />Phone # : <br />Date Tank Received: <br />AUErMfZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATM: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />