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SAN J•OAQLJIN LO HEALTH 01 s9mi GT <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. The holder of the _0,rmit with number noted below is respgnsible for <br />ensuring that this form is completed and return <br />®� <br />FACILITY NAME. <br />FACILITY ADDRESS: <br />TANK ID 139- lfqf - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />!r Z0 <br />Address: Zip: <br />Telephone: ) a-' Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: �•Zip: <br />Phone#: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may ated by Department of Health Services. <br />/,KGNAI <br />M AND TITLE <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 Name _ <br />Address: �7i1�'✓`°.lJ.. Zip, <br />Phone# : <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND TANK •*•VIV <br />P. • BOX 2009 <br />STOCKT,ONF <br />