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SAN .JOA tN 'LOC_AL_ HEALTH( \---)l STRS CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ********************�Y:l•***ir***:kik*:t;k:k*�c*�:AkAkk**:k9::kik:k:lel*k*ic:k:k**i:**il*:l**:ly::k**it***:kick**:k******* ,. <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: St. Josephs Hospital <br /> FACILITY ADDRESS: 1800 North California , Stocktnn, CA <br /> TANK ID #39- 163 <br /> *:C**:k�Y******�t�t******Yc*****�k****ic*ik:k:k:t•�kk:k:k:k*is�kii:l:kAX:I•*:k*:kk:k:lXi:;k;k:k:k:lkk*�k;k*:l********:k:kyt******�kic <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Western Meter Service, Inc. <br /> Address: 2735 Teepee Drive Suite E;- Stockton, CA Zip: 95205 <br /> Phone#: ( 209) 948-6124 <br /> Telephone: ( ) Date Tank Removed: <br /> ****ic*�*ic*X�Y*****it*�t*:k**:k****h�4*******:l**i�k�l;l•A•�k:l*X**Y�:l**�l:l•:k*:til*�Y**:k*�l*:k***;C**ir*ic*ic*:k***ic*** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Westprn MPtPr Scar vice, Tnrr_ <br /> Address: 2735 Teepee Drive, Suite E. , Stockton, CA Zip: _95205 <br /> Phone#: ( 209) 948-6124 <br /> Authorized representative of contractor certifigs by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> Wesley Dubose/ General Manager <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 <br /> is********7t**:k*****:kit****ic/Licit:k/[*it*:l•:lA*:l:t*iiic:k:litic:l*t**Ak:l**Jtk*itici:kic:l***:l 7k it*:k***�kic*****ic*yl***** . <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AT'TN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />