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1 <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />ztrxrxxxxxrtYx*xxxt*x***xxxrxxxxXx*xxxxzztzztxxxxXtzx*t*XxxXXxXXXXxxx******XX*rt**X*xxx*x <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 Healti. 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 ADDRE <br />AK ID 139-1(D.3�0 <br />i**Y*xxxxxx**xxxxx*X*xx*XxX*xxx**xx*xr*XXlX*xX**xrrx***X****x*******xt**rxxxY*x*XXX**r*Y* <br />'PION - 2 - To be filled out by tank removal contractor: <br />ik Removal Contractor <br />tress: <br />.ephone: 0/ �/G r S�SrP 6' Date Tank Removed: <br />TION 3 -To be filled out by contractor "decontaminating tank"/: <br />ik Decontamination" Contractor: <br />tress: <br />P: 9_f G1 <br />:a-.75/ 7 s -T s16 <br />ip: % .e�65 <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 />:zxxxx*XX*x*xxxxX*xXX*xXXx*Xxxxx*xx*XXX*X*xxx*xxxx*xxtx*XXXx*****XxxX*x*****xxxXXX*Xxxx*x <br />TION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />)rage, or disposal facyi;ity accepting tank. <br />7ility <br />tress: <br />e Tank Received: <br />�� <br />/ S'- _r i's S <br />AUTHORIZED SIGNATURE AND TITLE <br />xzzX*XxxX***zX**t**X**X***xXx*xxx*xx**xXt*x**x*x***tttxX*xx********XXr****x*xx**X**xxxxx <br />13 049 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 />SPOCKTON, CA 95202 <br />