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UNDERGF D TANK DISPOSITION TRACKING REI D <br /> !!!t!R!t!*!Y!t!x!!!!t*tlYRtt!!tYltRlYltRYltRtYRt*R!YlYtR!!!!R!R!R!tltRt!!*!**xt!!!!RxlYlxR! <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 facill//ty/Il The holder of the cermlt vithuh <br /> nor no low is r an,nafhl f <br /> FACILITY NAME: {//1L/ N O L S (A�/ <br /> FACILITY ADDRESS: / 6U /N /a U J 7-1a//AA- <br /> TANK ID 139- �1 - �. G(�(1C e '4C(lO,V e <br /> x!!!!x!lxxtxlxtttlxxxlR!!lRtYY!!YR!!t!lRttRlRtt!!!!tY!!!Rt!!lRttt*7tYttR!!*tR!*x*!!!!x*!!YR! <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 4SQ)(\C C7 <br /> Address: y�� \n> _ �o�C�n �� . Zip: S� <br /> n,___.: <br /> Telephone: (D-Zfl_)57-q"q(p5�3 Date Tank Removed: <br /> tlxRR!!!tltR!!lxxtRlRRlxRtltxxtt!!x!!!t!!!!*ttYltxltxYt*!Y!tlRYtRt!!Rtlxltxttltt!!x*Rt!lRRt <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decon"ination" Contracto j l Q1 ;1� �� /W6 <br /> j0 Ar <br /> �2n9'd'�7�iVJ /1lI�f�1.H-L <br /> Address: <br /> - Zip: <br /> Phone#: <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 /> xxxRxttttRR!!x!!!xlxxltxR#!!ltttRR!!txltltxttxtflR!lxRxRltR#!*"tt!!t*!RlxR!lxxt!!xx!!!*ttxt <br /> SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal/facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Q fHl�/O/V D felLPhone#- Z 67-6;235-/393 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xYtxtxRtRtYxlt*Y!t!*!!!!!t!!lYtt!lttt!!*!!fY!!!!!t!!t!*xlYttltRlxt*t!!tt*!tlRttlttltxltfR:! <br /> EH 23 019 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />