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�' 1r <br /> SAN J(DAQU I N L OC Al, HEALTH D I S TR I 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:- !�ir Ire e. ()c( I M 5 C- r Q <br /> FACILITY ADDRESS: <br /> -1-7-32, 5+6 K f yi <br /> TANK ID #39- $30 - <br /> SECTION - 2 - To be <br /> ill <br /> out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Telephone: ( ) Date Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 1 C C ( ; i oy) 5+C S <br /> Address: c) 41 5 . pe-f-5 1'\ 1 Zip: <br /> ,f2oc h Phone#: 1462 - '7� 4L— <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 />