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FROM 01 : 27.✓83 1 : 36 -' . <br /> SI►N .7(�I>►�C,JIN Lf7C2� F-I�"�T •'Y f ICY STI�Y C'Y" <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 fob <br /> crouring that this form is comply xetuxned. <br /> FACILITY NAM (9/k - I I <br /> FACILITY ADDRESS: 9 <br /> TANK ID 139- <br /> kRR***R***RRR*****RR**#R*#**R*R*R*RR**R*!*R*R*#***t****t*R***RR*RRRRR*#t*******RRkRRR**#tR* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:L_ Q�.4 1) , --)A i S I <br /> Address: �`1 31J0 l L� Qo �A,��_ �7i zip: <br /> Phone#: <br /> Telephone: ( �) U `J r� _ X35 Date Tank Removed: <br /> R**#RR*RRR***RRR**RR**k*tR*****t*R***R**Rtt*RRt*R***R**RR*RRRR*R**t*Rt*RBBB*R**t**RRR*t*YRR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: is I , oP7A (-JALI �l . Ora- Zi <br /> Phone#:=L� a53s <br /> AISL'I'ivk'lz. ] i`cpi2um,AaLly,� SL bcYLifiBb by 31+jnli,y Lc1Sw Ll"L Lim Lank l� Lnnii <br /> decontaminated in an approved manner as wIay be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> tR*R**RRR**Rt*RRRRRRRRRRRtRttkR**tRYRYttkkkktt*kYtY*kkR*R*YYYYkRkRRk*R#tktkR*kYkktkkk**t#k* <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility N // <br /> flame ( �iivv o n r � ) 1/Yl p n <br /> Address: , t;L �)'LrQ� ,/�2a e Zip. <br /> Phone#: .:'7/V- 9(11- ' SLl& <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *RRt*R*!R*RRRR#RRRRRRRR***R***t**k***kt*tRt*tRkR**Rtt*RRR**tt*kk*tk****t*tR*RRRRRR**R*kkRRR <br /> EH 23 049 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 7009 <br /> C70MTWI CA 95202 <br /> T - T <br />