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SAN .7021N x N LOCAL, <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> R*Rt*tt***tttt*#*R**ttt**tR**t*R****kR**RRRf!!RR#1t!#R*RktlR#RRRk*#**f****R*kt#**#t***t**RR <br /> SECTION 1 - The Sari 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 Hermit with number noted below Is r +mons ble fo <br /> ensurina that this form in completed and returned. <br /> FACILITY NAME; .. _..0. -7 #-,, <br /> � <br /> FACILITY ADDRESS <br /> TANK ID 139----L-Lid----- <br /> tMR*!**R****ttk#*f###*AR*tf**R*#ftt**R***RR*RR*#**kR**R*#RRRtRR#1RRR****RRRRR**tt**t*R*RR*Rt <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: e o r ems_, ,C� 1 I <br /> Address: `dao zjn� 0i9- Zip: <br /> Phone#: <br /> Telephone: �f: 535 Date Tank Removed: <br /> RR*R*t*k***t1R*R**RttRR**RR**R*R*R**RRR****RRR*****t*t**f*****RR*!***t**R*R**R*tR*RRtttRR** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address; LDO /a I , OGS 1 AL-t Zi <br /> Phone : - <br /> AtSL'11LY17en1 Ybjil'eisvi+L$tiVb of ZeoUai:tor e-a lLlCleb by balow tl'�L Uio La+J{ I�o Lvc+s <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> RktRRtRR*t*tttttRtt*tRtR*RR11RRt*RttRtRtkklRtt*ttRRRRRk1tRRtRRtt*t1ftRRk*ltttttRlRRRktRlltf <br /> SECTION A - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address; r,2 x,7-1 n ,, 4 X-e,, _ Zip: <br /> -ng o ,�T �C�/:�2 L I Phone#: �Y <br /> Date Tank Received; <br /> a .. <br /> ALR'HORIZED SIGNATURE AND TITLE <br /> *RR**R*R***k***R*R*RRk**RR*R*kRRtRR*R11R1RR***11f***#**RR11R*RkRRRRRR**RflkRRRRR**RRR*RRR1R <br /> EH 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATIN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> CT=TONn CA 05202 <br />