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SAW 4.7c)1641r4 T-80CALtA <br />1 x <br />p., <br />UNDERGROUND TANK DIRPOSIMON TRACKING REOORD <br />»ACTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification numbers The Tracking Sheet is to be returned to San <br />_Joaquin Local Health District within 30 days of a:mptance of the tank by disposal or <br />recycling facility. The holder of the22rdi th number -noted below is responsible for <br />Unser ing that this form ip co nmpleted and returned.. <br />FACILITY NAME:�i,,, <br />FACILITY ADDRESS- /9`/0 e <br />YTANK ID 139- _- <br />SECTION - 2 -- To be filled out by tank removal contractor: <br />Tank Removal Contractor: Z 7 U c % .� ? its ✓re .bra nytJ ,� Cep �Gn e . <br />Address: <br />cu c <br />Zip: .. vs <br />- 3.3 <br />Telephone: ( ) °L'- ` �.�.2 Date 'rank Removed t . <br />SECTION 3 -To be filled out by contractor "dedontaminating tank": <br />Tank Decontamination" Contractors. z z� ,jc r�✓i ;Er.V <br />dress: �,:��Q AA�ln,rli) Zip: 99'�Ic; <br />Phone# s 0611 <br />Authorized repre ntati contractor cerkifies by signing below that the tank has been <br />decontamindVeA IVay ov d me 4r as may Pe regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />`''SBCTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />1008torage, or disposal facility accepting tank. <br />` PAc11ity Name /`—; c l ' -- <br />°�, ddtess. �S` �' Zips cam ' <br />Phone# s -T <br />T <br />Dste Tank ceivedi, <br />Z04,6 YWirz P7 <br />AMHORIZED SIGNATURE AND TITLE <br />V1 23 049 12/88 <br />MAILING INSTRUCTIONS:. FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN : UNDERGROUND TANK PROGRAM <br />P. 0. BOX 7009 <br />STOCKTON, CA 95202 <br />