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SAN JOAQUIN LOCAL. HF A- -rH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD ' <br /> ******************************************************************************************* <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 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: QQL �FG,('j (o l D O <br /> FACILITY ADDRESS: PoLkA erson <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> c Vj t ti j j Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: S?vn <br /> Address: Zip: <br /> Phone#: <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 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name �� 17 �jG1 l� 'r V <br /> Address: A 0 ��� S� y� S f� Zip: G <br /> 5_;A x-166 ci, < 5 Phone#: <br /> Date Ta Received: "_22 — ' <br /> AI HORIZED SIGNATURE AND TITLE n <br /> Ell 13 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> r � 5 SAN JOAQUIN LOCAL HEALTH DISTRICT MAY 1 1 1990 <br /> G ATTN: UNDERGROUND TANK PROGRAM I'NVIRONMENTAL H <br /> P. 0. BOX 2009 PERMIT/SERVICES LTF <br /> STOCKTON, CA 95202 <br />