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f <br /> , <br /> SAN .70AQU I N LOCAL HEALTH D= STRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> /,x <br /> - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> th Its site identification number. The Tracking Sheet is to be returned to San <br /> cal Health District within 30 days of acceptance of the tank by disposal or <br /> facility. The holder of the permi's ith number noted below is responsible for <br /> naurinn that this form is Completed and returned' <br /> 'ACILITY NAME: <br /> 'AGILITY ADDRESS:��� l � ��25�' � <br /> ,'ANK ID 139- <F <br /> 3ECTION - 2 - To be filled out by tank removal contractor: <br /> Lank Removal Contractor: ,,,V!S J� �-t,/�' t' c����/CE � ,TIO•� � <br /> Wdress: � C_) / �iV �� QTc f��.iG4 Zip: <br /> Phone#: <br /> Celephone: ( �T ) �Y 6 —��J Date Tank Removed! <br /> 3ECTION 3 -To be filled out by contractor "decontaminating tank": <br /> rank Decontamination" Contractor: <br /> Address: Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> lecontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> k************************************k*k******kkx*******xx*k*******k***x**k***k***********k <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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EN 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 />