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SAN SOAQU2N LOCAL I-r�a�.r.TH DSSTR.2CT J <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******************************************************************************************* <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 nurTd�enoted below is res <br /> ensur inq that this `f/orm is compl�eyted and <br /> returned, pons ib1 P for <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID 039- - 0 C� 2^5 1aqn <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> - �p / ' �� ' <br /> • r Li�{IVt{ 1 7/�t�_�Y I��LS <br /> Tank Removal Contractor: s�i�dl_D C'O�jv Ll <br /> Address: -7 S_ lj���', 4/ <br /> low_ <br /> Zip <br /> Phoney: <br /> Telephone: Date Tank Removed: <br /> ******************************************************************************************* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: -7 /V ' <br /> -Zip: f� Q� <br /> - CI lW IC_N: <br /> 1 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be gelated b De <br /> y Department of Health Services. <br /> I 4A <br /> GN E TITLE <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 <br /> Address: Zip: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 ****************** <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AITIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />