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SA.LV .70AQLJIIV LOt-•err. HF�L�TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> MON 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> :fixed with Its site Identification number. The Tracking Sheet is to he returned to San <br /> ,aquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> :cycling facility. The holder f the pe--'t with number noted beiow 15 responsible for <br /> isurina that this form is completed and returned <br /> iCILITY NAME: ',N,,J (�- ACHOt C iLrtit,Lt-J-ltfl/ <br /> MLITY ADDRESS: Cy:17M - T 2c) ElArzo (v(n <br /> M ID 139- - D D �t� t��cc-C e �/ 4 fiti L- <br /> MON - 2 - To be filled out by tank removal contractor: <br /> ink Removal Contractor: .(Vicg S61(akn • =n1t <br /> idress: �3";LU o l4 kl k.0til �Sjndcove CA zip: <br /> Phonell��cF/) YEy £f 333 <br /> Aephone: (,,�o`( ) �{6t( - $ 5 Date Tank Removed: <br /> FX'TION 3 -To be filled out by contractor i4aating-tank": <br /> l5 ��L <br /> ank 9eee ' Contractor: t c scn� Tn� <br /> ddress: ��SS ����� BLVD Zip: Q '� <br /> lc�1i vlv(1D LIF Phone#:(U1 <br /> uthorized representative of contractor certifies by signing below that the tank has been <br /> econtaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> ECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> torage, or disposal facility accepting tank. <br />'acility Name <br /> ddress: _Zip: <br /> Phone#: <br /> kite Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> M 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 />