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A)W <br /> . SAN .JrOAQUI N LOCAL, T-�F'ao.T•TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RE20RD <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:_ _NQ G 6) 'Fav j \ k 12:4 # (o 1 D b <br /> FACILITY ADDRESS: 25-715 S• Pad e('SonSS <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: ] <br /> Tank Removal Contractor:— <br /> '" \ <br /> Address: ' 3 (, 4 1_ � �_ i �'�� C. ��� L.�LLI a��� Up.� <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �� C•� �l r;'��� /��S C� < <br /> Address: Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below t1vit 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 1facility accepting tank. <br /> Facility Name /7 T7 SA I <br /> Address: A - Zip: <br /> Phone#: <br /> Date an'k ceived: <br /> v <br /> Af1IHORIZ SIGNATURE AND 0 TITLE 'S "' n <br /> Elf 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DIS'T'RICT 1 1 1990 <br /> ATTN: UNDERGROUND TANK PROGRAM I'NVI <br /> P. 0. DOX 2009 RONMENTAL HEALTF' <br /> STOaMN, CA 95202 PERMIT/SERVICES <br />