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SAN JOiJ►QUI N LOCAL HEIAL.TI-I DI S•]'F2I C'I' <br /> LUpi30M TANG DISPOSITION TRAMM RWORD <br /> .tttftsfisifRftittffftitfffiif:tftfttfftRftttffttt*f**tffitfffttitttfttffifffffffftts:stt <br /> mON 1 - The San Joaquin Local Health District's Tracking S�tiwills to be any aach of Sank <br /> Mixed with its site Identification number. The TrackingSheet <br /> the tank by disposal or <br /> ,<,quin Local Health District within 30 days�of acceptance t with number noted_btankelow is disposal or for <br /> cycling facility. The holder of thC <br /> ur 1 that this in -m_,..te dnd .nrn. C _ ,c <br /> cILITY NAME: (,/./Z/ <br /> ,CILITY ADDRESS: <br /> ,NK ID 139- <br /> ..::ttf:tftftii:tittitttitttttttifiititfffRRffftiff:ff:fitititi:Rtt*f*f*R*R*:**f**ttfttttt <br /> ;C-TION - 2 - To be filled out by tank removal contractor: <br /> .ilk Removal Contractor: <br /> `.JGi/i 'i . �iJ ii/ iJ Zip: <br /> , tress: �" Phones: <br /> Lephone: (?,_1 1 �� '3 `> Date Tank Removed: <br /> ..:*ttfRRtttift:titttftRfttttttftftff:tefRRttiRftf►t::ftttt*tititttfi:ffffftfttttRRftiftRt <br /> -PION 3 -To be filled out by contractor "decontaminating tank": <br /> ,ilk Decontamination" l �L�OrC� �.r/��C7y SSG <br /> Contractor: E (� <br /> /f a6 au� 1411�T t Zip: q 5 Zl 3 <br /> dress: 1r _ _ Phones: Lq b 7/08 <br /> �-,InNll Loin � <br /> thorized representative of contractor certifies by signing below that the tank has been <br /> -ontaminated in an.approvmd manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> .zzttttflftltttffttftffttRfttttttf Rt/tfftftictftlttftttftfRfttRtRtftttffttRRftltftRt}ttttfitft <br /> CTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> )rage, or disposal facility accepting tank.' <br /> .cility Name <br /> Zip: <br /> dress: phones: <br /> ,t.e Tank Received: <br /> AUT H RIZED SI(;1ATUR& AND TITLE <br /> .xttRtttftfttfttriitititiittattitttttft►ttffitttftftffttitttttittfftttffRtRffRftttfRttfRt <br /> 23 019 12/88 <br /> tLING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROBER POSTAGE. <br /> SAN JOAQUIN LOCM. HEALTH DISTRICT <br /> ATTN: L*MCROUND TANK PROGRAM <br /> p. o. BOX 2009 <br /> STOCKTON, CA 95202 <br />