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SAN a0AiQU1%,-V LOCAL HU AL'I'H ITt Sa'EZI CT <br />**********xxx****xxx***x**x*x****x**xx*x*x***x*xx*xx**sxx**xx*x**x**xxx*xxxxxxxxx***xxxx* <br />:,TION 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 />iquin Local Health District within 30 days of acceptance of the tank by disposal or <br />zycling facility. The holder of the oermit with number noted below is responsible for <br />'ILITY NAME: <br />'ILITY ADDRESS: <br />JK ID #39-__-��_ <br />tx**zzzzz**x*zx*******x*****xxx***********x*x**xx******x***x***x****x*****x**zz**x******* <br />`TION - 2 - To be filled out by tank removal contractor: <br />ik Removal Contractor <br />Iress: Zip: <br />et i—e Phone#:A2 7 `/ S % T 'a <br />ephone: (2 9' 4101' S S�f'� 6 Date Tank Removed: <br /><*z*xz*****x******xx***xx****x*xx*****x*x**z**********x*xxxx**xx*****xx***x*x************ <br />TION 3 -To be filled out by contractor "decontaminating tank": <br />O� <br />do Decontamination" Contractor: 71 <br />` <br />Iress: <br />s?� i AV Ce. V ez . / Zip: <br />e v. CIQ Phone#: <br />:horized representative of contractor certifies by signing below that the tank has been <br />:ontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />xxxxxx****x*****xx**********x******x**xx*xxx****zx***x*x**x***x***zx****xx*******x****x* <br />TION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />)rage, or dispusal facility accepting tank. <br />-ility <br />.rens: <br />e Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />23 049 12/88 <br />LING 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 />ip: D <br />