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• WN Loci <br /> .Jc» <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> 9t**3t 9c�Yk*'Y****�***;kir�c�k;k*k*�k*aF*�k�:***�k*Jc*�::k**ik*ic'kri*%*•kAk*:k**�;%�:�:�:**:lk*�k*:E9c**�c�r�C9ciksk�C*�Li�**:r 9c�k*icic <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each San rtank <br /> affixed with its site identification number. The Tracking Sheet is to be returned <br /> Joaquin Local Health District within 30 clays of acceptance of the tank by disposal or <br /> recycling facility. The holder of the rmit with nun]_�er noted below is res nsible for <br /> ensurin that this form is completed and returned. <br /> F,A.CXLITY NAME: <br /> 1 t ' �Z <br /> FACILI`T'Y ADDRESS: <br /> pl o2,a3 <br /> *7r*Yc�k3::19k'M�'�r�r]C�k3k�F Y*9CYc7r�c*i;k�kk�Y�l'kak9ckik7�*;kFk�:9;**kK:t;kl k:k:#ik*:k:t�x:k�l�c';l'�':kr:*�rk�l k�'�tl kk*Y:�k�s�kat;k**�c9c:rYtkit-k:l' <br /> SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_-E_2L � l <br /> Address: f + , s,,-. Vr"�c�- P': , 7`%c� "rQA_j Zip: <br /> — _ Phone#: /2,0q <br /> Telephone: (T ) Date Tank Removed: <br /> �:*9c�:Jc*9t:lig•:rxk*�r*kk***�t*kirX*•k:: kk�s*•3:k*;1�:*7k*J::kklkAxk:l*Ak1*�*�;****n:4**x*k**A:tk:r* Fk**�sk*fir**�cic'*%�c** <br /> SEC'T'ICN 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: <br /> Address: ti.� - `Zip: <br /> Phone# . <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 TI'I'LE <br /> it�t7tk*7Cy:*ick**ir�t�k�t**%***Yt*1t*:k*ic*7kkF:�tk*'k�c�i�;X*'kk'kkkkA9C*k**x'yc*5Y**Jl;l•****F�k�':r'k*7Y%9ri[kic*%*ic*�k9c9[*it*ic <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: Zip: <br /> -- Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *:sk <br /> EF. 23 049 12/88 <br /> MAILING INSTRUM ONS: FOLD It! HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JGAnUIIq LOCAL HEALTH DISTRICT <br /> ATTN: uNDE:RGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOcKTON, CA 95202 <br />