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SAN JJOAQLJI N LOCAL. HFAr.TH DI S r CT <br /> " S' <br /> 16 1990 <br /> UNDERGROUND TANK DISPOSITION 'TRACKING RECORD i P(,jti(N!r Pei rA+L''�/H� A L T. <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:_QSL 0 'F0,r 1 \\� # (o l D b <br /> FACILITY ADDRESS: 25-775 S• Pk. terson Pass Q. <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> / <br /> Tank Removal Contractor: T ( teL. j> <br /> Address: C( C`Lk'dc L (���� �iyc 'l Zip: <br /> z7 Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 1?c lelCz.17 <br /> Address: -3 � �f /e C� _ /�0 ��' Z ip: // l._S <br /> Phone#: <//{ <br /> Authorized representative of contractor certifies by signing below tYkit 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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name_d il 9 sh/j Is .l-ya( //U L <br /> Address: /N Zip: 9119 <br /> ISM) rA 141 <br /> 0 Phone#: <br /> Da Ta Received: <br /> AIJPHORIZ D SIC24ATURE AND TITLE I <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �1AY 11 1990 <br /> ATTN: UNDERGOOUND TANK PROGRAM r-WRONMENTAL HEALTF- <br /> P. o. BOX 2009 <br /> STOCKTON, CA 95202 PERMIT/SERVICES � <br />