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SEP 11 '89 16:53 308 Pat <br /> EMU .7C )AQLJI N L.00AT. HmjkrlprH IaI Sa1R T CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> Pr*****Pr***x*w**Ww**xxPrw**************kPrwww**xw***WwPrw**Pr**wPrPr*PrwWkwkwfiPr*Pr*w*****W***xxwxxxfi <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. Thome holder of the pg�mit� with numhar nO�Qd below is regRgDAW4T, for <br /> ensurinn th0t this form is,,QMlgte3 a0d retUXned. <br /> FACILITY NAME:'/ n <br /> FACILITY ADDRESS: <br /> TANK ID 039-• <br /> SEMION - 2 - To be filled out by tank removal contractor- <br /> Tank Removal Contractor: �y <br /> Address: Zi 7. �b91 <br /> Phonef, �L6•- 72.- Ictb'b <br /> Telephone: (_ ) Date Tank Removed: <br /> w*****x**xRx***wXfi****x*xPr**RR*R*******PrX**wWfix********�*wkxxxwwWwwWw*****W*WxPrXX*w*PrPr**xx* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �_AW�S <br /> Address: �2�"; (�� l r� I WAOc?/ /moi/C� zip: _ C� <br /> Z.: Phonew. �� <br /> Authorized representative of contractor certifies by signing below that the tank has I-Aen <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITL,F <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address. I ug_ _Drr�,a 1 �i3C7l '7 7 �b�j zi r, 1�ro"7 <br /> 64"_�Ay1� r� l'rL! �e PhoneO: 1LyYSf <br /> Ades Tank Received; INDTE TANK NOT RECEIVED AT THIS TINE, UPON RECEIPT ANOTHER COPY WILL BE <br /> __— <br /> CEVELAND VALREY, OPERATIONS COORDINATOR <br /> AUTHORIZED SIM AND: <br /> *w***Prx** ***Wxx**R***k***kxX*ww*Xk********w*fiW*XkXwfi***xwwwx x***Ww**xw *xw*xx <br /> Elf 23 049 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. A6F'1X PROPER POSTAM, <br /> SAN JOAS2UI14 LOCAL IMALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. Box 2009 <br /> STOCKTCN, CA 95202 <br />