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SAN 7C)AQLTIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******************************************************************************************* <br /> S*@C'I'ION 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 responsible for <br /> ensuring that this form is completed and returned, <br /> FACILITY NAME: QQG n (o l D 0 <br /> FACILITY ADDRESS:__Z5�15 S• �a Et^Sa nSS Pte(. �T(, � <br /> TANK ID #39- 7(_'4_' - 2- <br /> SECTION <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below ttklt 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 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE n <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' 11 1990 <br /> ATTN: UNDERGROUND TANK PROGRAM r-NVIRONMENTAL HEALTF <br /> P. 0. BOX 2009 PERMIT/SERVICES <br /> STOCKTON, CA 95202 <br />