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1 <br />c � . <br />SAN .70 QUIN LOCAL HEpr. • DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />*wWwwww***w**w**wwww*ww**x*****w***www*w**w*****w*wxwwwww**wx**wx*wx*xxaxxxx*xxx*xxx***xw*w <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 />JoaquiLocal <br />Health District dwithhinL300 days acceptance of the tank by disposal or <br />recyclintir noted Fw1nw is responsible for <br />FACILITY NAME:[ OCpti' <br />FACILITY ADDRESS.) o / <br />TANK ID 839- ENVIR'. `T✓' <br />SECTION - 2 - To be filled out I)y tank removal contractor: ra P s'aTY <br />Tank Removal Contractor: r r u i : c SM. <br />Address: c v-rrn Zip:` <br />Phone#: <br />Telephone: (1'01 7 3(014 as Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": Q F_GotJT*M`I~ *"M <br />3 (SOU, J.1441 <br />„ <br />-FALCON ENERGY ASSOCIATES c.v T M O - 1'D Nou , 1411 <br />Tank Decontamination Contractor. <br />Address: M, Box 30356, STOCKTON, CALIFORNIA <br />Lipi95213 <br />a <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 />SIGNMIJMt ANL) TiTLL: <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facili$4 accepting tank. <br />Facility <br />Address: <br />Date Tank <br />AIJPHORIZ SIGNATURE AND TITLE <br />