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:.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 />=ycling facility. The holder of the permit with number noted below is responsible for <br />urino that this form is completed and returned <br />'ILITY NAME <br />'ILITY ADDRS <br />dK ID M39- <br />TION - 2 - To be filled out by tank removal contractor: <br />ik Removal Contractor <br />tress: <br />ephone: (26 cl ��GS S&'8o� Date Tank Removed: <br />TION 3 -To be filled out by contractor "decontaminating tank"/: <br />ik Decontamination" Contractor: t r Oy 7"` f e� / [_ C „ { 7Z <br />tress: <br />IP:9f.�C.�e_— <br />ip: , ?G <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 />TION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />)rage, or disposal fagi;ity accepting tank. <br />'ility Name /L,A La / L o n c%i i, <br />tress: <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 />