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WTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />(fixed with its site identification number. The Tracking Sheet is to be returned to Sart, <br />oaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />ecycling facility. WUIer Qf the in w,Uotmbernoted below ible for <br />DgyA�� that We fora In c leted and Returned. <br />ACILITY :' C --OA) �� C <br />� � 1i Y �I. � / i rt/�i i ♦ � <br />ANK ID 139- <br />*��t**est*it:*�e*seftestft�t�tssa�***�*��rs*s�*****�*�**s**�*ss******�t�**�r*��r**�**its�tx�t��****s���tit* <br />ACTION - 2 - To be filled out by tank removal contractor: <br />ank Removal Contractor:—<77`r)e--jC M -,j v r//ClG .53^��f1TU+�c J Za <br />Zip: <br />: ;elGl/ 9,353 <br />WrION 3 -To be filled out . "decontaminating <br />ank Decontamination" <br />ddress: Zip: <br />Phonal: <br />uthorized representative of contractor certifies by signing below that the tank has been <br />econtaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />*s*t�tts�s�ttt**•s**ie�s��*,�tt�s*str�����tr�x�s�s�**���tttt*stt*s�*tctt�ttttsx*�s�**it**ttssits*�**��**�tts� <br />DCTION , - To be filled oft and signed by an authorized represnetative of the treatment, <br />forage, or disposal facility accepting tank. <br />anility Name <br />_ <br />Zip: <br />Phone#: <br />Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />N 23 049 12/88 <br />ILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />r• <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />