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UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 />:ycling facility. The holder of the permit with number noted below is responsible for <br />'ILITY NAME: <br />;ILITY ADDRESS: - 2 �, d U <br />NK ID 1139--2&—?&-� <br />TION - 2 - To be filled out by tank removal contractor: <br />lk Removal Contractor <br />tress <br />P: 9S :. C. c& <br />2,� -/ �7- <br />ephone: (2G q)/>i� S�S�B46' Date Tank Removed: <br />TION 3 -To be filled out by contractor "decontaminating tank": <br />do Decontamination" Contractor: IY6,v �` ( c� / L C i+ f 7Z <br />tress: <br />/ �V CG ✓ !f . /w / Zi/p::'C% <br />phone#: ZL <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 />:*XXk#kk**#*k**#!i*ki**iii***iXk*#k*k***kkk*i*i**Xk**kikkk**kki****#k*kikkkk***Xkk*ik*k*k <br />TION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />,rage, or disposal fasi;ity accepting tank. <br />-ility <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 />ip: 1D S� <br />