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SAN .70AQUIN LOCAI� *-*�ar.TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ***,e**xr,r*,r*,r****xWr,rx****r*****r****�,r*s*»**a*x*rr�e*s*�x*x:x�*�t**�r�,+,e,r,r�**�****,e*��*,exx**x■ <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 the permit with number noted bel-ow is respgnsible for <br /> ensuring that-this�� form is completed and returned, <br /> FACILITY NAME: 0-31en e ca ., Trays or'-�-aX OLS <br /> FACILITY ADDRESS: q Iq P' r 0 ham. c+4 r Lc / <br /> TANK ID M39- <br /> tttttttttttttttttttttttttt��****ttttttttttttttttttttttttttxx**,t***t*pax**a*xrt*xxa*x**x**�inr <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: l l)P �(4n(1T 1 P ()z 111L)P <br /> Address: (n <br /> Zip: <br /> � PhoneM; <br /> Telephone: (o) W1`I_ ,!:�2Qa_Date Tank Removed: <br /> **ttwr,e*��r�****t*t�*t*xrr�txt,r�*x*t*w*,e**Ott*ir**se***x*ttt*t*t�tr*gat**,t*tt**ftWx*��*ttrrxtt�t�*t�� <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: <br /> Phone#L_'"X7el <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 /> eaxxz,e,ix,c****�**x�xxxxxx***a****x*xx*:t*x*,ta*rr**a*rca***,t,exxxx*xx*xx**t�txt,rxr*xx,t><*rnerr*a***x <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 UJ )\( 7� , <br /> Address: Zip: _CLCi <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> tttttt***tttttttttttart***ttt*ttttttttttttttttttttt�*tttttttt*tttt*tt*�***ttt*****tttttttttt <br /> Ell 13 049 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 /> STOCKTON, CA 95202 <br />