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't <br />SAN JOA�7LTIN L,GC"-AT• HEALTH D'SSTR2CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />SD TION 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 return <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: S7c2o- Al 1 FRN /NAL <br />'T <br />FACILITY ADDRESS: 20a,�_ y✓.Q2f (TO/�Y� _1�rstl��D/✓ CA - <br />TANK ID #39- <br />SECTION <br />39 SECTION - 2 - To be filled out by. tank removal contractor: <br />Tank Removal Contractor: <br />Address:_ j �rG'2 7G� �7 CJcitr»r/� eIA Zip: Gi"'2oS` <br />Phone#: I.ZOA2 !241e— 6 12 <br />Telephone: ( ) Date Tank Removed: <br />SDX7TION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: j� T_CaQ'eG I-)TT<�GIC4 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 />Date Tank Received: <br />ip: <br />AUTHORIZED SIGNATURE AND TITLE <br />EH 23 099 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 />