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SAN .7OAQUJN LQC.Pr HEA_T=H D1S1rR2CT <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—Eo San <br />Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the wrmit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: 4�/, — csTrutt 9i✓ <br />FACILITY ADDRESS: �� �/, %��J �! iL�Y�y LST—et{fit CA - <br />TANK ID #39- IL4 - � y <br />SECPIaN - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: %'� j -g' �'�2� �7br/.+Nn! C Zip: a4n2oS' <br />Phone# : f'704 ) 9WG 6 <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 --To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: _2=7: — i -� �G. /y Zip: <br />Phone# :. /�p�1 �y/� b rla( <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 />AUTHORIZED SIGNATURE AND TITLE <br />EH 23 049 12188 <br />HAILING 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 />