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SAM' 70AQU2IV LOCAL 14—.P STH D= STR2 CT <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:_ 514aw S���IL �D:T L.� <br /> FACILITY ADDRESS: g3js �,J/a-F�i�d�X> f��/!✓ �;GkTU►-1 <br /> TANK ID .#39- - <br /> SECTION - 2 - To be filled out :by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address. Z- h, A '. Zip: 945`}S <br /> Phone#: 1115)_7763- 7Sc0 <br /> Telephone ( IS' ) 7 E33--1 SU U Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination". Contractor: _Tr T�GIZ- IZ,�ll <br /> Address: ZiD: 94S4S <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in aniapproved 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 0121 SIC. <br /> Address: 45- ./ Zip: (A <br /> L' !� Phone#: <br /> Date Tank Received: <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 PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />