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SAN .?OAQUIN LOCAL Hmz,r_ <br /> -'� TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SUCTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The TrackingSheet is <br /> Joaquin Local Health District within 30 days of acceptance of the tankob�disturned to San <br /> recycling facility. The hold of he - r i wl L Y posal or <br /> ensuring that this form is compl�eyted and re urned, r of d bel w i, re s big for <br /> FACILITY NAME• <br /> FACILITY ADDRESS: � <br /> TANK ID N39- _ <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: 135y (/ <br /> .�-T�ifl /��Q Zip• �7 <br /> Telephone: <br /> Phone 8: <br /> (��� )_��¢��/� pate Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor• sZ5'%,?Faz, <br /> Address: <br /> Zip: IO� <br /> ----_._.._Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as ma <br /> Y be gelated by Department of Health Services. <br /> IGNATURE TITLE <br /> *�r�r* **, <br /> Sr <br /> ECTION 9 - To be filled out and signed by an authorized represnetative of the <br /> storage, or disposal facility accepting tank. ent <br /> Facility Name � 1 <br /> Address: <br /> Zip: <br /> Date Tank Received: <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. <br /> AI'!'IX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISIMICT <br /> ATTN: UNDMGROUND TANK PROCPAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />