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°- SAN .TOAQ,� N LOCP,I., HF•AI,TH � STRI CT <br />Q0,•!-• 1 $ ► •t t - 5*0il <br />MON 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 San <br />aquin Local Health District within 30 days of acceptance of the tank by disposal or <br />cycling facility. The holder of the permit with n no <br />surina that t°�=Y �+urned,- aw-tonsible for <br />his form i c completed a .. <br />CILITY NAME: <br />C`ILITY ADDRE <br />#W ID 839--�_-� <br />*#******#****##########tt##ttttttt#ttttttt###ttttttttttttttt#tt#####tt###tt#t###tt###*#* <br />TION - 2 - To be filled out by tank removal contractor: <br />ik Removal Contractor: <br />3ress: <br />lephone: ( ) Date Tank Removed: <br />TION 3 -To be filled out by contractor "decontaminating tank": <br />* Decontamination" Contractor: <br />Zip: 9r.201 <br />Zip: y0 / <br />Phone 84- .?v 7 l 4/! 5""- S e d <br />:horized representative of contractor certifies by signing below that the tank has been <br />contaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />:TION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />)rage, or disposal facility accepting tank. <br />:ility Name <br />tress: <br />:e Tank Received: <br />Zip: <br />8: <br />AMMIZED SIGNATURE AM TITLE <br />23 049 22/88 <br />LING IMTRUCTIONis: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UiDIFRGp4M TAMC PRoGp M <br />P. O. BOX 2009 <br />STOCKTQN, Ch 95202 <br />