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SAN JOAQI JI N rOcAr HHAr TH 1DI STRI CT <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 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:—AP-C-0 'Far j , 1 An4 -ii (o t o O <br /> FACILITY ADDRESS: Z5-7-7S Pa,ki erson pass <br /> TANK ID #39- <br /> ******************************************************************************************* <br /> SECTION - 2 - To be filled out by tank removal contractor: / <br /> Tank Removal Contractor: <br /> Address: 6 .3 �S �� �`I. 011e c l <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> n _ <br /> Address: �: � j /c� ' zip: <br /> �; l <br /> Phone#: yis `4j, G «E' <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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name �/`� �7 ��1 1 ( C- <br /> Address: <br /> C. C,�\�� iN I�c',< <�t f Zip. % 7 <br /> S r1►L' �►:I;,r, s Phone#: S` 40 S <br /> Da Wank Rece iv - 61 ' <br /> �1,111'ugj Ix G <br /> v d <br /> AUTH IZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT MAY 1 11990 <br /> ATTN: UNDERGROUND TANK PROGRAM PNVIPONMENTAL HEALTH <br /> P. 0. BOX 2009 PERMIT/SERVICES <br /> STOCKTON, CA 95202 <br />