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l .. <br />SAN JOACTN :C OCAS IIEALTH�S STF�S CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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. The holder of the r)ermit with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: rr-ow,ILu4A4L gest <br />FACILITY ADDRESS: 3cio /�/ GOYTctti�o ¢� 4i2�1 4�2G�" <br />TANK ID #39- /S7a - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: WQS-�cvv._ ✓yk!?=� 6,e -r. <br />Address: A735 1 +- PPS Aje. S%r-k-la , Zip: <br />Phone#:- <br />9� <br />Telephone: -AC)!2 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: We6tcm-,� 6k, -,r - <br />Address: rt7_3S C',,_ 96-2os- Zip: <br />Phone#: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services <br />SIGNATURE AND `TITLE <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 <br />Address <br />ip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />EH 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />A'ITN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOC'KTON, CA 95202 <br />