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�VI <br />s A.N -702-!LQ[.TIN LOC_,AL, % =- Ar.rrm DISTRICT• <br />UNDERGROUND TAMC DISPOSITION TRACKINC RECORD <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. i4� hQ.�eX__of the nr�rml�wwh rnu��ber n�,t �x w is rc'spQnsible for <br />ensur._incl h,t t- is £oXm_ is _--ted a a <br />FACILITY NAM: <br />�-/��� Li/iQs <br />FACILITY ADDRESS:7`Fa� <br />TANK ID 139-_./ <br />SWrION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: �.�.UL.0 <br />.,i - <br />Address: <br />ip :�,­ <br />Telephone: <br />�)-� �l�y`-� Date Tank Removed : <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank <br />Tank Decontamination" Contractor:I��-t/ <br />Address: <br />Zip . tel <br />Phone 1: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may h Mated by De <br />partment of Health Services. <br />,rt (-,NA'llms AND TI.TLE <br />wwwwwww*www*wwwwww www ww w'*w*w*ww>r*****w**w�rw**it***xww**wirwirw*w�rwwwww*x*irwir,rwir*wir*ir <br />SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Nametir^H�v <br />Address: _ -��/G�7Zvy ;czm�� <br />Phone 1: <br />Date Tank Received: �� �s�� <br />w****w**wwwwwwwwwwwwww*w wwww*tDCN AND <br />*wxw**wwww*wrtwwwwwwwwwwwirw*iriritw>r*wir*�r <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALT' AND STAPLE. p'I)( PROPER POSTAGT. <br />SAN JOAQUIN LOCAL !JEMTH DISTRICT <br />ATTN: UNDERGROUND TANK PROCRAM <br />P. O. BOX 2009 <br />SMMTON, CA 95202 <br />