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SAN �?OAQUS N LOCAL. HE.P,LTH DZ STR2 C`I' <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 clays of acceptance of the tank by disposal or <br />recycling facility. The holder of the rmi with number noted below is responsible for <br />en_ surinq that_this form, is completed and returned. <br />FACILITY NAME: S (F S <br />FACILITY ADDRE.SS:_L_j; /c'c.I,Z�4A74PnjO <br />TANK ID #39- --) <br />SECTION -- 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: r <br />Address: c. <br />Phone# : <br />Telephone: p Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank".- <br />Tank <br />ank":Tank Decontamination" Contractor: ; <br />Address: . P 0, /?,,"_0 <br />-- ._ Zip: a / <br />Phone# : <br />00 <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 />SICZ4ATURt 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 <br />Address: <br />Zip: <br />Phone#: S a <br />Date Tank Received: <br />ED***GN*�rTL!RE*,�AA�ID**x* TITLE <br />*�r�r**�r**rr*�a�*�r*******�r**�*��*** <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDEZGROUND TANK PROGRAM <br />P. O. BOX 2409 <br />STOCKTON, CA 95202 <br />