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SAN 00P VIN LOCAL FIEAL.Tl DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxxxxxxxxxxxxxx**x*fixfix*z*xx***fixfi*fififixx**xxfififixxx*fizfixzzx**fi***fiz*fi**fixfi***********xfifixfifi <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 tbg permit with number noted be w is responsible for <br /> ensuring that this form is completed and r��etnrned <br /> FACILITY NAME: �'�� E'dr'YO /lF'C. �,' �, CiuR / i:UkRS5 JS <br /> ,�J �T ec an:;ai District 02058 <br /> FACILITY ADDRESS: L j O(J GU, G E7/7�� ���i cs� (Si 3650 '•y. conal <br /> TANK ID 039- 770/7-e- Tracy, CA. 95376 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ly '-'er\1� __Cny <br /> Address: 1 S -Tee oce- Jr E� Zip: <br /> Sin 4+ A gSaos Phone#: <br /> Telephone: ( 20� S �) iag Date Tank Removed: <br /> **xfifi**fifi****fi******fi****fifi**x*fifi*xfifi******fifi*xxfi*xxfix*fix********fix**fi*fix*fi***xfifi*****fi**fi* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: j rim n d -, <br /> Address: nd Ue Zip: <br /> S ✓✓�/nFn Phone#: 9� <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> ***fi**fi*********fifi*fi**fifix*fifi**fififi**fifi*fifix*fi*xfifix***fifi*x*fifi**fi*****fi*fi******fifi**fi**fi*xfi*fi*** <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 I✓'i' ing _fn� <br /> Address: a S C,2"j QUI!, Zip: <br /> St�✓aeiieA4o Phone#: cIf(6 q,)_1 I 17t9 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 13 049 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />