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` i ! + . ED 1W Z_* 14064 <br />*7k**�t�k7klt�***7k**7kilt*9lrilr4lr*7k*7k***iC�*Sk*�k7t1k9tihiF�Ylk�kitilc*it9tlCyksk�k�tY�9t�t*****st***�tikit$�'k*itlt*FcltSk�iit*lY7k�kiC�t9Fit***** <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification number. The Tracking Sheet is to be returned to San <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The boldprof thermit with number notcd bglgw ig re g2ogIbleor <br />enguring that this form is gom„Dleted and returned. <br />FACILITY NAME:-(" V, R rp lit' P. C `, fYa i 4-, v a <br />FACILITY SS: �iC7 D �% /�C5 12,'s�S p�� },, /A 9-12 9.�y <br />TANK ID 139- - <br />SECTION - 2 - To be filled/gout by tank removal contractor: <br />Tank Removal Contractor: c .. r / i , e) ,_j P c f) ti i A <br />Phone <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: C_V"r <br />Address: 3 9 " 6G Le sr Z i5.a2 t3 <br />Ip: <br />Phone # : - 2 3i :«.$ <br />Authorized representative of contractor certifies by signing below that the tank has been <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 Name ---,C,,-1 0 a `' <br />Address: V y <br />Date Tank Received-: <br />3 <br />�r7tit*fk*itSklt"kicitlFltSk�iY�F�Jti�ir'fi***ikitc*ikYt4i�r�cir�kit*7k*st*iYitiF**itiiik*ik**iiahiF*'sY:t**It'ik**ifr**ik*�l'*'lkitiilt4iiRikh'�k7trit*:t�kiF*'R <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCALADISTRICT <br />UNDERGROUND TANK PROGRAM <br />P. • BOX 2009 <br />STOCKTON, CA95202 <br />M <br />