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SAN JOA V <br /> xN Y.or�,L. IIEAL.'i � szRxc�r <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ***************X*********k*k*k********X*A**k***1tA*k*AR**k***X**R*kA*********************k** <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 hOldez of thmlt with ntLmr,_ngted below 14 aamnaihln f <br /> ensurina that this form is compplet.a and returned <br /> FACILITY NAME• && —j)LV_S / 411V Tf <1 Ai 1" <br /> FACILITY ADDRESS: � / '�2 SL L11\1C-f2 S77- <br /> TANK ID N39- 7 - <br /> **X*kA****A****A*********kk*****k*******k**kk**A**************A******k******kk*R*X**kk***** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> '' <br /> Address: 7`3/ C'�J. H/17T%�L �j� , _ Zip: 535 <br /> r r7 ,.i rr U ff . Phone#: <br /> Telephone: (A 1 ) _'j;7�- 9 h 5 Date Tank Removed: <br /> k**k*k***k*kk**********k*******kk***********k***********k**********k**Xk***XA***XXk****X*** <br /> SEjCTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: %r / CV • _/� 7��I h� Zip: <br /> L%fJF_C /�4 Phone#: S�;-�4 /,s--:,. <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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name / eL' <br /> Address: 21p: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ******kk********kA****k****A*******k*********kk***k******k**k******k**k*********k*k**Xk*k** <br /> EH 13 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />