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SAN JC UI N LOCAL ImAL.': DISTRICT <br /> . . < .. <br /> UNDERGROUND TAMC DISPOtSITION TACKING 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 J <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. j ' <br /> 7 <br /> MAL— <br /> FACILITY NAME. y <br /> FACILITY ADDRESS: <br /> TAMC ID 839 <br /> **�#�**t�tttt##�#*#tttttttttttttttttttttts�:re#��s��r*�#suet***�#esteee:e##+rte##��*�t*e��r#�** , <br /> SCTION - 2 - To be Filled out by tank removal .contractor: <br /> Tank Removal Contractor: 60M.Gc�, <br /> • w ,a-rc �sro <br /> Address. Zip: <br /> Telephone: t 4_2E,5_15 Date Tank Removed: i <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" 'Contractors <br /> Address: T Zip: 3,,,-,/ <br /> Phone,: <br /> Authorized representative of contractor certifies by signing below that the tank has been'''2 <br /> decontaminated in an approved 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 <br /> Address: k2E S "- . ' L C OUG Zip; <br /> Date Tank Received: <br /> AUTHORIZED SIGNATLRE AND TITLE <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALp AND STAPLE. AGFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: .lJc(DMMOUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTCH� CA, 95202'7. h . <br />