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^71N J02�.0LJ]:I1 L0CcT1_C. IILZ+i1=,TH DISTRIC'i' <br /> UNDLIRGROLAID TANK DISPOSITION TRACKING RECORD <br /> #AAk*k#kk*k******AR******k#***************#**#*********R#k*#**********R****RR**#RR**RRR#*R* <br /> W-310N 1 - The S:m Joagnln Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its ::lte ldnntification 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 /> rec)r_ling facility. ` ,TLP hoj.c)e-r_f:Ulte_Lxacmll_wlt number noted below is restwrLslble for <br /> ensuring Lhal this form is comUleted aA r(!turned. <br /> FACILITY NAVE:_ Rel. <br /> FACILITY ADDRESS: 171Y-6*� L) , CIMP'rAALLeiA) f='�� zrAt1/ <br /> TANK ID 139- `� �GOQ G <br /> *RRR**#*#k*R#Rk#*# R*****##*R#k*#*#**#**#*R*#*******k#*******R**#*****#*R**kR#*RR*#RR*R#RRR <br /> SECTI(Al - 2 - To the filled out by tank removal contractor:' i <br /> Tank Removal Contractor: CV T ' N <br /> Address: /" I r/'f`AL CJ l_ Zip: SJR <br /> Phonel: q <br /> Telephone: ( .Zm )_ � ?�Q Date Tank Removed: <br /> **#R##*****RRR##****RR**R**R***R*****#**RR**#***R***#RRR**#R****RRR*R*R**RBBB*k*RRRRRR#RR*R <br /> SECTION 3. -To be filled out by contractor "decontaminating tank": ' <br /> n v <br /> Tank Decontamination" contractor: l ' L <br /> Address: 55 �AIJ1 � � Zip: g� <br /> Phonel: Y)5 235 13cY3 <br /> i <br /> Authorize s a ve o contractor certifies by signing below that the tank has been <br /> deco ml ed an a Prov d manner as may egulated by Department of Health Services. <br /> SiCNA'IIIIRG AND T T.,E <br /> R*R*****#* R**R#R** ******#****#*R*************#*# *#***R*******#**R*RR***Rk*#*RRR*******R <br /> SECTION 4 - To be f led out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> , <br /> Facility Name =,/lit k_g�{�/� gj AAX <br /> Address: Riva!KIC.' InA_006 CIA <br /> om , Zip. lJd � <br /> Phonel: x11,5_3 K /.3q3 <br /> Date Tank Received: <br /> A4IVWILF <br /> D SIGNAIL4R AND TLE <br /> EN 13 049 11/11 <br /> NAILING INSTRUCTIONS: FOLD IN STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> AM: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />