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-- �' /7 <br /> S.ArI a C]A [32 N: "L 0 C.AL. HF'A?'•TIS[ " D 2 S TER T CT <br /> UNDEItMOt1ND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will acco�any 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 ttie 'permit with number noted below is responsible for <br /> ensuring that this form is completed'and" returned.-_ <br /> FACILITY NAhE: '� w} 7c6A <br /> { Y j wY; <br /> FACILITY ADDRESS: 4:�3(asDfk`J " Z+9� `� �`�( " G ' " " <br /> / } APS <br /> TA.''iK ID 939-- <br /> SECTION -- 2 - To be filled out by tank' removal contractor: PERMIT/ V!CS <br /> Tank Removal Contractor: Co <br /> address: !2-40-J t! L. �� . Zip. �✓�� <br /> Phone#: <br /> Telephone: ( ) ..Date Tank Removed: <br /> SECTION 3 -To be tilied out by contractor "decontaminating tank": <br /> n`a Decontamination" Contractor: <br /> Address. 293 _ i G dip: °LSO( <br /> "Phone#• - 4�" <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 /> LA- <br /> SIGNATURE AND TI •• <br /> SECTION 4 - To t filled out and signed Py an authorised represnetative of "the treabT�ent, <br /> storage, or disposal facility accepting tank. <br /> Facility Name. <br /> j <br /> r <br /> AL-idre5s: 7-Z 7— `�• ,�1L1a 4ut- <br /> Phone#: l � <br /> Date Tank Received: <br /> I�, r (� X-4_ pert <br /> .Y'r�}1 T1s A 0 U`; `� <br /> AiJTHORIZEO ;;SIGNATURE AND TfTLE <br /> Err 23 049 1.2188 <br /> MAILING INSTRl3 TIONS: FOLD IN HALF AND? STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUiN LOCAL REALTii DISTRICT <br /> ATTN: ' UNDERGROUND TANK PROGEZ M <br /> P. 0..; PDX 2009 <br /> STOCKTON, CA 95202 <br />