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r STRr CT <br />UNDERGROUND TANK DISPOSITION TRACKING REOpRD <br />SECTION' 1 -The San. Joaquin Local Health Districtis <br />affixed with its site identification number, Tracking Sheet will accompany tank <br />Joaquin Local. Health District within 30 days ofTacceptancegofhthe tanto Pant each tank <br />recycling facilit be returned to San <br />ens— u�4'that this £orm ishcomer of letedth:e retuxneath number noted k by disposal or <br />t�elow is res onsible for <br />FACILITY NA1•E: 4LL/--/ ,e <br />FACILITY ADDRESS: <br />TANK ID 139 ._l.3;Z& -t. <br />2 - To be. filled out by tank removal- contractor:• <br />Tank Removal Contractor:.��! (.E5 <br />c�cS7-, <br />Address': 51M Jt- 2 x1D A, <br />Phone#Z�pI�j� <br />Telephone: <br />I ,10 <br />bate Tank Removed: <br />SECTION 3 -To be filled out by contractor "deconfaminating'tank": <br />Tank..Decontamination" Contractor: <br />T_ <br />Address: r,--2 <br />Zip: I S�E3Ze <br />ve of contractor certifies Phonefl: 911.4 1990 <br />Authorized repre5entati <br />decontaminated In an :approved manner as by Signing below that the tank has been <br />Y be <br />regulated by Department of Health Services. <br />SIGNA <br />TLJ1 ' AND TITLE <br />SMTION 4 To be filled out and signed by an authorf�e <br />`storage, or disposal faCility Signed <br />tank:, d represnetative•of the treatm <br />Facil�ity.Name_ .;'d,�,��=,�r•._ ent, <br />Address: <br />Date Tank <br />(Z_ . <br />Zip: <br />�!i zJ T�tE AND TITLE <br />D!9 iz/99 <br />MAILING INSTRUCTIONS, FOLD IN.HAI-p.AND STAPLE. <br />Ar <br />FIX PROPER POSTAGE. <br />-SAN JOAQUIN LOCAL HEALTH <br />DISTRICT JUN 1 5 t9yU <br />Arm: UNDERMOUND TAA'K PROGFAM <br />P' 0. 13OX 2009 �NVIRUrdrtgeiy�� 1� <br />q""CXTON, CA 95202 RMS �r <br />