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identification40 Z <br />CTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />fix,ed with its site <br />number. <br />aquin Local Health District 1 days of ♦ r, <br />e Of the tank by disposal or <br />cycling facility. The holder of the UC131t with nUMWX UQW-below In rea2gnsjUe fgr <br />CILITY : <br />CILITY S: <br />ik Removal Contractor: <br />;'H S /etc <br />r r I <br />. • _ <br />__jDate Tank - • <br />"TION• be -y • by <br />Iress: enrj O,'I ° ® C Zip: <br />Phoned <br />:horized representative of contractor certifies by signing below that the tank has been <br />.ontaminated in an approved manner as nay be regulated by Department nt of Health Services. <br />SIGNATIME AM <br />TLE <br />t*:�***�**s�iritlr:itsR:crit*�**t*�*its*ss*crit*ititstskst�:,r�,r�**�***x***�*****�*****�r�t�r�trr*,�**xc*�r**x <br />`TION 7 - To be filled out and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting <br />tank. <br />:ility Name <br />cress <br />Zip: <br />Phone#: <br />:e Tank Received: <br />hinimiZED SIGNATURE AND TITLE <br />**sssk#ski#�:�*:***sk#st>kstsl<sRlsRskslnk*stskstfnksksksk�*sksRltit*�:�*#tsksRslrlsRssestskststsRsR#shit*sksksksk*******:�*it*�*** <br />23 049 12/88 <br />LING INSTRUCTIONS: IN my I Am STMa. MFIX <br />SM JOAWIN LWALHEALTH DISTRICT <br />i BOX 2009 <br />