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SAN JOAt_ JT N LOCAL, I-iF��ar-Tk-__.DT STF2I C'I• <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 to San <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 n�""ner nnrad below is *a�oonsible for <br /> ensuring that this form is MQIeted and gSjUX 0j <br /> FACILITY NAME: _F-,L &e&Q2 Z40Vef77-_k2&A1T"S <br /> FACILITY ADDRESS: #� LN/✓ J11/jDl7� / Z� C� <br /> 5 �y <br /> TANK ID 139- )-?, _p L <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: PYi\ Cry <br /> Address: q�31� We4L zip: <br /> P <br /> Phone#: 5 ZU S3 <br /> Telephone: (aO9 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" CContractor: SQyy�C x ) <br /> Address: LI te,'PK+61 <br /> X1kWRffA!-.z k A zip: 9635! <br /> Phone#: �ZZ_ - l�— <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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name Ser" C7 <br /> Address: l zip <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED siwiTURE AND TITLE <br /> iN 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. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />