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SALV J02>,QU=N LOC_rr. HFAr.TH D= STRICT <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 be returned to San <br /> Aquln Local Health District within 30 days of acceptance of the tank by disposal or <br /> :cycling facility. The holder of the permit with number noted below is responsible for <br /> :sur!na that this form IN completed and returned, <br /> MLITY NAME:SN t,_N �F6(a&. l \ VA" <br /> MLITY ADDRESS: CC1AnC--T7}I U VIN-y <br /> +NII ID 139- <br /> MON - 2 - To be filled out by tank removal contractor: <br /> ink Removal Contractor:--- IfE&u-1 i7 • Znl c_. <br /> ldreass _�� y I��o , 1 �\ s c�.,l �T C•Tocl OA CA zip: <br /> —� <br /> Phonell��rj) yby-$333 <br /> elephone: 0204 ) Ci6c{ _ $ �-� Date Tank Removed: <br /> R�r�#R*fi******fi*******fi**fi*********#*##fiRR <br /> ECTION 3 -To be filled out by contractor '�sC SAwlaating tank": <br /> ink 4 c5f1L <br /> t�' Contractor: <br /> #dress: SSS -D" <br /> np l3Lyp Zip; - 3 <br /> ic}� �m�n� t 1F Phoneld� y�)33�, 39 <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 Iiealth 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 /> ate Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> M 23 049 12/11 <br /> SAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL 11EALTI1 DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br /> s <br />