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L <br /> QU2 N LOCAL F EE AT•TH D2 ' _TZ CT <br /> UNDERGROUND TANK DISPOSITION 'IRA&ING RECORD <br /> i 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 Permit with number noted bel w is responsible for <br /> ensurincLthat this form is completed and returned. <br /> FACILITY NAME:— f L <br /> FACILITY ADDRESS: (2 V A.). A /19 4v,. 11 <br /> i <br /> TAMC ID 139- - d <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> ii <br /> Tank Removal Contractor 3 i k.)X-.S a-- LAO , <br /> Address: of YO j E DN 71-- /=�/r.SN O �',s <br /> -- -- _ Zip: Q/ <br /> 'a Phone#: �/X <br /> Telephone: `-Date Tank Removed: <br /> *�r <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �{ <br /> �i <br /> Address: <br /> 0 Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an ap <br /> proved mamner as ma be pegulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> I SECTION 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: ZZ.OZ '5 MlLL1Kj !! Zip: fl7Lol <br /> ,t <br /> Date Tank Rete' ed: <br /> 11 <br /> AUTHORIZED SIGNATURE AND TITLE01 <br /> S!f 23 049 12/88 I . <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER'POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTfRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 t <br /> STOCCTON, CA 95.202 <br />