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1 <br /> SAN 7O21LQu1N LOCAT. Mmzs, .TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />/Local <br /> San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> site identification number. The Tracking Sheet is to be returned to San <br /> tank <br />!c li city.lth Dine hoideristrict tofnthe t)er30 miofwith ntumbernotedance of ebelow is de$ sal or <br /> ycy nG:ble for <br /> uxing that this form is completed and returned, <br /> CILITY NAME: CRQ k 6t �_, t-\� ti\1 'T7,rh rn FAT <br /> ,-7 /I <br /> CILITY ADDRESS: ! r-k (\t e5 <br /> ID #39- <br /> ION - 2 - To be filled out by tank removal contractor: <br /> nk Removal Contractor: s\�C- fo <br /> rens: c�S�� 7\lc� tl a� .� v7- 4 ZIP: C� <br /> Phone#: a - 3 <br /> lephone: ( ) Date Tank Removed: <br /> ION 3 -To be filled out by contractor "decontaminating tank": <br /> n, Decontamination" Contractor: =—Rlcc� <br /> ar sg: s pp\ 13 �n Zig+ <br /> c1/1 Phone#:C l5 �3.� - 3`)3 <br /> thorized representative of contractor certifies by signing below that the tank has been <br /> contaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> ION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> orage, or disposal facility accepting tank. <br /> cility Name <br /> ress: zip: <br /> Phone#: <br /> to Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> 23 019 12/88 <br /> ILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCA, HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />