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SAN .JOAQT N T..00IA r. HF A' = L S TR2 CT a <br /> - <br /> UNDERGROUND TANK DISPOSITION TRACKING RE <br /> 1 <br /> y�. x�t*ir***x***#*4tx**#*xx*xxxxx******ir***itx***x**xit�►***x*xxxxxxxxx*******x*********xx*x*�r�**x <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> V;".:'affixed"with its site identification number. The Tracking Sheet is to be returned to San <br /> r�Joa in Local Health District within 30 days of acceptance o£ the tank b disposal� Y P y poral or <br /> r ii facility. The holder of the permit with number not low is responsible for p <br /> ecyc Y• gd..�_ <br /> =ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> e <br /> ''_:FACILITY ADDRESS:�� C(4 <br /> TANK ID #39-c�3 ? - �-- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: E S ,,�_()... Z 0 7-R _�Zf5p Vle-F- , /}yr_ <br /> Address: a . C Zip: ti <br /> Phone#: <br /> Telephone: ( ) ! y/2= Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> .Tank Decontamination" Contractor: ��F S'�" , ?Z� r. ,, <br /> to <br /> Address: v P r TAl C eq Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been c <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SEMON 4 - 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: ._� <br /> Zip: <br /> Phone#: i <br /> . r� <br /> Date Tank Received: <br /> 4: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 ` <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. - AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOC KTON, CA 95202 <br />