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•, ,. •; <br />TrackingUNDERGROWD TAW DISPOSITION TRAOCING RECORD <br />CTION 1 - The San Joaquin Local Health District's <br />fix,ed with its site Sheet will accompany <br />identification•. Sheet <br />aquin Local Health District within 30 days of acceptance Of the tank by disposal or <br />cycling facility. MM holdr <br />• •y , - • <br />cILITY : <br />!NK ID 139- <br />+cfc#st*ir**rt�*•r:xus:x*x*s�*>x�itR�t*�*i�R>x�*#**it**tie*ftittRitftltlrlrlit*hitt********ittk*�******it�ititit�kir��* <br />:TION - 2 - To be filled out by tank removal contractor: <br />ARM <br />s r -Zip: ZE201 <br />• <br />r y <br />Date • <br />• be filled out by • <br />` • �:; . • • <br />Cr9 <br />cress : / J a g- C+ r - <br />Zip: <br />Ph #Eo <br />:horized representative of contractor certifies by signing below that the tank has been <br />:ontaminated in an a r may be regulated <br />by Department of Health Services. <br />SIMMURE AND TITLE <br />e*****�***��*�t*tit*t*�x*ts***ttte*��*�r**t�***t*�*�**�r**#**�*pit•cs******�**�*****�t***�r*��t**�* <br />:TION , - To be filled out and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting tank. <br />:ility Name <br />gess: <br />Zip: <br />Phone#: <br />:e Tank Received: <br />AUTHORIZED SIQQTURE AND TITLE <br />23 049 12/ss <br />LING INS•i =IaNS: F= INHMy AMSTMZ. AFFIX I PR4PZR'p0STA(Z. <br />SAN JOAQUIN8' DISTRICT <br />UNncRcaOUNDTAW•' •C' <br />• .• 2009 <br />•r M <br />