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0 C T 1 r, ,Cad <br /> SAN J QAQU I N L OCAL HMAX 7'H D I S TT EN 0NMENTAL HEALTH <br /> .t FEi<M!TJSERVICES <br /> UNDERGROUND TANK DISPOSITION TRACKING RECOn <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 clays of acceptance of the tank by disposal or <br /> recycling facility. The holder of the r>ermit with number noted below is res onsible for <br /> ensuring tat this form is completed and returned. <br /> FACILITY NAME: S ' o r2 AT o <br /> FACILITY ADDRESS: 400 vJes_1_ <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal contractor: <br /> Address: �"1 l Zip: 'T5 6y 1 <br /> Phone#: 7 - 11'7 -7 <br /> Telephone: ( R► ) 3TC - 11 -? Date Tank Removed: �,ove EF12-- <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: h\JAL. , rel C-N�,r z '21NG=k <br /> Address: tZ Zip: �5i� 9! <br /> rPhone#:(4 1 7 32 - ��-7 <br /> r 12 <br /> Authorized representative of contractor certifies by signing below thtit 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 /> Facility Name C Qom F Ci u E"J-1- <br /> Zi <br /> Address: 11 '315 �nu7'r► f2iP6c — p: 9S�� O <br /> �aN� o ori-�cav C_F Phone#: qL 35- <br /> Date Tank Received: <br /> AUTHORIZED SICNATURE AND TITLE <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE . AI'FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL fEALTH DISTRICT <br /> ATTN: UNDMGROUND TANK PROCRAM <br /> p. o. PAX 2009 <br /> sT,o CON, CA 95202 <br />