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SAN J'OAQL.T3:N LOC.AI.r HFA T. ��� 2 4 ISS <br /> UNDERCtOUND TAMC DISPOSITION TRACKING RECORDA LT <br /> . SECTION I The San Joaquin Local Health District's <br /> TrackingTracking <br /> SheetSheet <br /> iswill <br /> to beaccompany <br /> returnedeach <br /> to Santank <br /> affixed with its site identification number. <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the hermit with number noted below is responsible for <br /> ensuring that this �foorrm-is completed_ and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 12 <br /> TANK ID #39- 104Z - (J <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:— -z4 <br /> Address: 2��7�. ��. V �C'VV ll '-„ vt�-Y Z i ! 7 <br /> Phone#. <br /> Telephone: t ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 4 <br /> Address: i 1 <br /> � �� � 1 42S�t�1 Z1p; Cl53b. <br /> Phone#: Fm-474-Lq44 <br /> Authorized representative of contractor certifies by signing below ths�t 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 N-, {v l � �_ -- <br /> Address: (Lt(3 p. <br /> zi f7fo � <br /> p Phone#: 7t44 <br /> Date Tank Received: <br /> AUTHOATZED SIGMA AND TITLE <br /> Elf 23 049 I2/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />