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SAI`l' .70AQU2N LOCAL, HEAT�TH D= STRICT <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 for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME:_ 5140w 5���/ILG S-r�Tiv <br /> FACILITY ADDRESS:_ 9 3j5 �,�lp�—T'�(2{1,1p �/� �j"[LGI�Tc�►a <br /> TANK ID .#39— — <br /> SECTION - 2 - To be filled out :by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address. • A A \i Zip: 94545 <br /> Cxs Phone#: IS)7f33- -1SCC> <br /> Telephone ( IS )JF33-1SUU Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination". Contractor: <br /> Address: ZiD: 94S4S <br /> A n• .�• Phone#: �4►.S, ��3-�S[�d <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 /> 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 Cw Kscf <br /> Address: , N/t> Zip: 91601 <br /> L.' A Phone# : (41-5)Z36- 1393 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Elf 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 PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />