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�? 190 14:24 R.H.L.,'�CRAMENTO 9166464679 <br />� • •AtCEIVEC. <br />MAY 15 1990 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTh <br />- <br />UNDERGROUND TANK. DISPOSITIQN '>:'Etl#CKING RECORD l ' <br />111 SERVICES <br />SECTION 1 - The San Joaquin Local. Health District's Track''ing Sheet <br />will accompany each tank affixed with its site identification per.. <br />The Track Iing Sheet is to be returned to San Joaquin Local Health w <br />District within 30 day:of acceptance of the tank by d' osal or <br />recycling facility. The holder of the permit with number n "0_TALHEALTF' <br />is responsible for ensuring that this form is completed and retur i��sFq\prr" <br />FACILITY NAME:_- I � �G `{ �(%:_P Q �1 Ht' ' i <br />V'ACILITY ADDRESS: --- S ~i -)-L_ 190VQ� 7(i Y TANK ID # 39_ 1 '7 - L <br />SEMIQN 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: ZASQ Phone <br />Zip!9 <br />Date Tank Removed - `- - 90 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank "Decontamination" Contractor <br />Address DC7 S T phone # <br />Zip <br />QA - <br />Author' d representative of contractor certifies -by signing <br />below th t the tank s been decontaminated in an approved manner <br />as y regulate partment 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. C <br />Facility Name f fc%C5 or► J , , <br />Address- � �4,y Phone#15.0515-ISI � <br />Date MW Rece i <br />AgVRORIZEtYWATIM AND TrrLE <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />AZTN: UNDERGROUND TANK PROGRAM <br />P.O. BOX 20091 5TOCKTONI, CA gszol <br />