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S71LV J0.2',QLJIN LdCZ1L I-II�AL.'.I'H L7I STF2I C'1' <br /> UNDERGROUND TANK DISPOSITION 1IZACRING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site ldontificatlon number. '? ' The Tracking Sheet is to be returned to San <br /> Joaquin Local Ilealth District within 30 days of. acceptance of the tank by disposal or <br /> recycling facility. j"hehoolder_of Ule vermit with number noted below is respgnslble for <br /> ensuring that this form is completed aril returnees <br /> FACILITY NAME:_ P,,Fl. <br /> FACILITY ADDRESS: f 7V-5" IV , Cm rrAL k} LL .) EJ 1 f AL1/ <br /> TANK ID 139- 13*76 -' (� J- , edP (, A.� <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: iZf bAllrcl' <br /> Address: 1Ze <br /> Zip: U&7 <br /> �l /Phonee##: 83`i-/7_frn <br /> Telephone: ( 209) gJ'�6� 0 4 Date Tank Removed: <br /> SECTION 3. -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: zip: <br /> y�0 <br /> Phone#: - � <br /> AuthorI <br /> senta a of ontractor certifies by signing below that the tank has been <br /> decontn ap rov mann r as may be ulated by Department of Health Services. <br /> n <br /> t <br /> SIGIAIUR.. ND T E <br /> ****R*SECTIOe lied out and signed by an authorized represnetative of the treatment, <br /> storagos 1 facility accepting tank. <br /> Facility Name <br /> Address: O <br /> Phone#: 9 <br /> Date Tank Received: <br /> AUTHORIZED S AI'CIRE AND TI7 <br /> Ell 23 049 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL EALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCYTON, CA 95202 <br />