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SAI -1 7C:)A0TjjN :C_OC-A_T --I= rl--rE, <br />AT j DSS.T <br />UNDERGROeND TANK DISPOSITION TRACKING RECORD <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 facility. The holder of the hermit with number noted below is <br />responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: 'Ti Me OtL- � T4c--1e-(?d7r- SmPrr-I,= (WJ <br />FACILITY ADDRESS: I *j 4 00r-ie�n>o,� rLo A -o CD <br />TANK ID #39- <br />4 <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: (AI ESTE n" �errm\. "C' <br />-5� .4 <br />Address: -L' C�- I ) r I L) Q� - E, zip: <br />"i C -2- 0 cy -P hone N C -L on, 94a -4i:_.4 <br />Telephone: 20ei q 14 4B - (c I Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": -;T <br />Tank Decontamination" Contractor: U4 e ST&-TLAA <br />'Address <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 />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />1 . <br />Facility <br />.Address: <br />Date Tank Received: <br />Zip: <br />AUTHORIZED SIGNATURE AND TITLE <br />SH 23 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. IJ'FIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STCCXT'DN, CA 95202 <br />