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APR 27 '90 14:24 R.H.L r-"ACRAMEMTO 9166464679 P. <br />r <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING REMRD <br />SECTION l - The San Joaquin Local Health District's Trackinqlf�eiet4 <br />will accompany each tank affixed with its site identification number. <br />The Tracking Sheet is to be returned to San .Joaquin Local Health <br />District within 30 days Of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted above <br />is responsible for ensuring that this form is completed and returned. <br />FACILITY NAME: Ac Y 1% '' IFACILITY ADDRESS : P(}IC Y TANK ID #39 t -7- <br />SECTION 2 - To be filled out by tank removal Contractor: <br />Tank Removal Contractor.����„ <br />Address: ? 1 %,o TQ ATrA t- Phone <br />1 - <br />Date Tank Removed <br />SWTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank "Decontamination" Contractor IUI <br />Address -hone# <br />Authorized representative of contractor zip - <br />certifies -by signing <br />below that the tank has been decontaminated in an approved manner <br />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 <br />representative of the treatment, storage, or disposal, facility <br />accepting tank. ��^^ <br />FACility Name G Al <br />AddressPhone# <br />zip. �r <br />Date Tank Received <br />AUTHORIZED SIGNATURE AND TITLE <br />MAZING INSTRUCTIONS,. Fold in half and staple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRM <br />P.O. BOX 2009' STOCkTobi l CGA gszot <br />