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r ' 90 14:24 R . H . L . fc4CRAMENTG 916646 1679 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />P.3/3 <br />RECEIVED <br />MAY 15 1990 <br />ENVIRONMENTAL HEALTH <br />lytI(SERVICES. <br />UNDERGROUND WANK. DISPOSITION TRACKINGE2ECbE2D �ZI�� <br />SECTION 1 - The San Joaquin Local Health District's Trac3'Ing Sheet <br />will accompany each tank affixed with its site identification ptamb0. -, <br />The Tracking Sheet is to be xeturned to San Joaquin Local Health N <br />District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number no! AWPk1ALHEALTP <br />is responsible for ensuring that this form is completed and retur g�SFR\iirr" <br />FACILITY NAME: " I AC, -r i_- P .Q_ H l'a t H 6.e t <br />FACILITY ADDRESS: 3_7.1-L 1 teKY R lft-11 TANK ID #39-_1±2-.!0 <br />SECTION 2 - To be filled out by tank removal Contractor: <br />Tank Removal Contractor:, <br />Address: ZV1cDQ 9_phone <br />u 1 Zip 1 <br />Date Tank Removed��- <br />SECTION 3 - To be filled out by contzactor "decontaminating tank": <br />Tank "Decontamination" Contractor <br /><`+ddres5 (Phone #/S <br />--OA -1:!�Z% zip <br />,.�. <br />Autho 'zed representative of contractor certifies -by signing <br />bel hat the tank K#s been decontaminated in an approved manner <br />as may be regulat partment of Health Service. <br />SIGNA'T'URE 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 <br />Address. ' ._.P^ ( C.V . Phone # �'`� 3';• 1 sl <br />Date Tab netd_ <br />�;1,�9 <br />M*W* ZED SIGMA AND TITLE <br />* * * X * * * at <br />MAILING INSTRLr-TIONS; Fold in half and staple. Affix proper postage. <br />SAN JOAQUIN LOCAL HMTH DISTRICT <br />ATTN-. UNDERGROUND TANK PROGRAM <br />P.O. BOX 20091 5TOC KTO n/ , CA c15201 <br />