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SAN J OAQU2 N L©CA.L HEALTH D= STR=CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD • <br /> SECTION l - 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 /> Joaquid Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The-holder of thg MrMjt with r noted bel w is-respqnsible for <br /> ens"r t this -form is completed and returned <br /> FACILITY NAME:""" ,VT-ig <br /> d KT <br /> FACILITY ADMESS: eAlthFtA <br /> TAMC ID 139-- A:517-i5 - /- <br /> SDCTION -- 2 -- To be filled out by ranx/removal contractor: <br /> Tank Removal Contractor: <br /> Address: 80,< /1)6/', fes/ AIA �f9lit_ �.3'i� Zip: <br /> Phone#<2=7�3 21-773., <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: eAP_ -S 3 7-- <br /> Address: P Box ziar ��5��q /if��T _ . _ _, zip: �•3•Zy� <br /> Phone 0 44� 9 <br /> Authorized representative of contractor certifies by signing below t1kit 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 authorised represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Faei 1 i ty Name \ <br /> Address: . ��� .'R. • Zip: <br /> S< < Phone#: <br /> Date Tank Rece ived: <br /> ` W <br /> AUTHORIZED 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 <br /> ATTN: UNDERGROUND TANK PROD M <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />