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SArr .Tov=rr L.o REC ERED <br /> . CAL, H�nr-TH D2 S <br /> UNDQ2GROUND TAMC 'DISPOSITION TRACKING MR <br /> ENVIRONMENTAL HEALTH <br /> SECTION 1 - The San Joaquin Local.Health District's Tracking Sheet will accompany ****** <br /> affixed with its site identification number. The Tracking Sheet is to be rrneda to Sank <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 resaonsible for <br /> ensuring that this form is completed and returned _ <br /> FACILITY NAME: � �,1 _ <br /> FACILITY ADDRESS: 2 1-5c. CL��fZ lj k . .5TC(_ V_ .4 <br /> TANK ID #39- f � - DI _ <br /> SECTION - 2 - To be Filled out by tank removal contractor: <br /> Tank Removal Contractor: �a\ <br /> Address: -- Z- � ��- 1 U 7J M ` ' Y Zi q5z-74 <br /> Phone#. <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank"• '770 Fkcci�l <br /> Tank Decontamination" Contractor: <br /> Address: Zip: �S <br /> Phone#: -471+-46+44 <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 �r_ <br /> Address: '22c72 (V1(1.�.� �N �.. �, �3-(Liv Zip: eq <br /> Phone#: ���-CCr�-070 <br /> Date Tank Received: 4 <br /> At HOAIZED SIGMA 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 <br /> ATTN: UNDERGROUND TANK PROM M <br /> P. 0. BOX 2009 <br /> STC=TON, CA 95202 <br />