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SAN JOA IN L,C?c" AX, HFjU_.'I'j4Mby <br /> UNDERGROUND 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. Tbg holdgrgntnrw <br /> ensuring that thisffo m is completed and retur,no e r <br /> FACILITY NAME: I <br /> FACILITY ADDRESS: o� <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 's F/yq Gt, <br /> Address: Zip: ` <br /> Phone#: <br /> Telephone: i ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: rQ_�� CA) <br /> Address: /l { V - ' (,� Zip 9s-m?dill <1 / <br /> Phone#: �3 <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 <br /> Address: Z <br /> J^''l u E,_L�� _ C}.�; '� Zip: <br /> - Phone##: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HF.ALTNN DtBTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> S`Z'OC KTON, CA 95202 <br />