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SAN JOAC2VIN LOCAL HFA.r.TH DISTRICiP�a3 ., Tr�l�1 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> kfiww*twtxxt:ttkttwxttxwxxxxtfixfi*fixxww*kfiwwxkfifiwwwxk*wwkwwwwwfi:kfifikxxfififixx*xx*ttfitttae�ali���}rw <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 pALSarL <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or?A'- `S <br /> recycling facility. The holder of thgmit w1th number noted below is responsible for <br /> ensuring that-this form 1,5-- m <br /> FACILITY NAME: �G �Pefz�7! /fie AS <br /> FACILITY ADDRESS: 2 5 -7 tkc) rQ ) U t Seo c-kfaAJ <br /> TANK ID #39- 1990 , <br /> *fifi**x**xt:ttxfikwfitw*x*fix*wx*wfi*wx*fififi***x*wx*wxx*fitkfifit*x*wx*xwfi*kxxxwfik*t <br /> SECTION - 2 - To be filled out by tank removal contractor: 1C C `fALTH <br /> FERMIT!SERVICES <br /> J _ <br /> Tanis Removal Contractor: Lk <br /> �t <br /> Address: C-) L� . ( k nw�1 Zip: C <br /> Phone#: <br /> Telephone: ( <br /> ,2 Date Tank Removed: <br /> xwfifififiw**xtx*x***kfixx*fix*fikwfi**fixk*xfik kfifi**fifififi**fi***fifi**fi**fi*fixxxk**xxfi*x*xxkfixx**x*fix*fi* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: a� <br /> Phone# <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approveder as y be regulated by Department of Health Services. <br /> aAA I.f , <br /> SIGNATURE AND-TTII'LE <br /> fifi*fik*fi********x**fix****x*wfitkkkx*kfixkfikkxk*xx*kkkkfikxk*wfifikfifi**fik*k*xfi**kfifi*fixfi*fix**k*fifi*x <br /> SECTION 9 - To be filled out arca signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting <br /> fepting tank. <br /> Facility Name_ - ( Allo %c,.,l S <br /> Address: n K Zip: <br /> Phone#: <br /> Date Tank Received: - <br /> a _ <br /> F <br /> AUTHORIZED SIGNATURE AND TITW <br /> fiat*fi**fixwxx**xx*txx**xt*x**x*fi*k*xk*fikfififififi**xt*fifi*wfi*wt *fix**fix*xx*****x*k*x***tt*x**xk** <br /> EH 23 049 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 />