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S zl_lV .7 02'�.Q N <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />***********�c7k********�;***7['*7t*l"*:k*•A:�*1::k'1:A!:•.�'k�'*�iik:l'lYck*y:tA:lkA'3l'*kA-:S•Jki:i*�cici:iTicar**yc*ix�•*!r****ykst*7cit* <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 permit with number noted below is r.esr>ons_ible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: 1, <br />TANK ID #39 <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />I Address <br />Zip:S2o,-5— <br />one#: 9Z'g <br />Telephone: (,20q Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": - <br />Tank Decontamination11 Contractor: <br />IAddress: <br />e.. <br />AR L <br />Zip: 9.�e L <br />Phone# : _9e�K_ <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 />/ /% / <br />/ SIGNATURE AND TITLE <br />A***t*****-k*****Yti:*ik:k*�i'*i *i 7k t* tires*7c t7k7tX* <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />rens <br />to Tank deceived: <br />Zip: <br />Phone#: <br />AUTHORIZED SIGNATURE AND TITLE <br />k4)*ILING <br />23 049 12/88 <br />INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL 14EALTI-I DISTRICT <br />AWN: UNDERGPOUND TANK PROMAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />