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SALMI .j02)1.QU2I1j LOCAL, I3F rrH D= STRI (__T <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <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 Dermit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME:- 5140w 5���/ILE S-fA:n <br /> FACILITY ADDRESS: g 3 is i,J�.-r�ruUt✓ S�%c kTU►� <br /> TANK ID .#39- - <br /> SECTION - 2 - To be filled outby tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: MZ_ ZiD: 45.4 <br /> Phone#: 441S)763- 7ScD <br /> Telephone:, ( IS )"7 E33-�1 Sy U Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination". Contractor: <br /> Address: Zip: 9+S4S <br /> Phone#: <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 /> ******k**ic�C*****yC�k**�C*�C*ic**7F*iciC*�; kir*it�F*3C*********lcic9c******iric*icic*ic9c9C9C7k9c**ic*itic*ic****ir*icir9t�k**ic <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.Name C-,2j <br /> Address: ./ Zip: 91601 <br /> LA Phone#: (AIS)2,36 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E!! 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 />