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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />/District <br /> N 1 - The San Joaquin Local Health District's Tracking Sheet <br /> ccompany each tank affixed with its site identification number. <br /> racking Sheet is to be returned to San Joaquin Local Health <br /> within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: 1/y <br /> FACILITY ADDRESS: CZA^&_/1t0r()E]&TpNK ID #39-_&eq-01 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S��I�Tp rf .S',c p ii,U� r� A& <br /> Address:_ a0 /VIO � L'� phone # 5 <br /> ZipS— <br /> Date Tank Removed <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> * x x * x x x * * * * x * * x * * x * * * x * * * * x x x * * * x x * <br /> SECTION 9 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> * * x x x * x * * x * x * x x * x x x * * * * x * x * x * x * x x x * <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 20091 5Tor kTon1 ) CA g52o1 <br />