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0 <br /> SAIV JOAQOTN LOCAL HF--A�TH DISTRICT <br /> f UNDERGROUND TANK DISPOSITION TRACKING <br /> 1x1****x*1*11*1****1x*1 <br /> SECTION 1 - The San Joa <br /> q,in Local affixed with its site identificatlonantlumberstrict's Tracking Sheet will accompany <br /> Joaquin Local Health District within 30 days of acc acceptanceofto <br /> kob each tank <br /> recycling facilit be returned to San <br /> ensuring t s The holder of. he 1 Withy disposal or <br /> s f rm Is completed ar r dw <br /> o <br /> FACILITY NAME: I <br /> FACILITY ADDRESS: <br /> 7 <br /> TANK ID <br /> SECTION - 2 - To be filled out by taint removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> 3J7 <br /> � ps <br /> Telephone: ( PhoneM: C' 31 <br /> Date Tank Removed., <br /> SECTION 3 -To be filled out by contractor " x********811 <br /> Tank Decontamination" Contractor; decontaminating tank": <br /> i <br /> Address: r L' � � �• <br /> 1 <br /> AuthorizedrepresentativePhoneM?iP <br /> Inan of contractor certifies by signln <br /> decontaminated in an approved manner as <br /> may be regulated by signingbelow that the tank has been <br /> Department of Health Services. <br /> IMAT <br /> SECTION <br /> *1*x***18*8 filled Akk****1******x**Rk*x********xx*xfi**x*11**x*x*1x <br /> AND TITLE <br /> SECTION 9 - To be filled out and signed b <br /> storage, or disposal facilit acce y an authorized represnetative of the treatment, <br /> Y piing tank. <br /> Facility Name C I <br /> Address: L <br /> Zip' 3 �U <br /> Date Tank Received: Phone N: <br /> IZE <br /> Ell 23 049 121881x111xx***11881*��*1 *x*D****�*x***x*************x****xx**xxx***xxxxx* <br /> Ell ?J Of9 12/88 ZE AND TITLE <br /> MAILING INSTRUCTIONS: FOLD IN AND STAPLE.A HA[F 1x1*x** <br /> SAN ALF N AFFIX PROPER POSTAGE. <br /> JOALOCAL IEALTH DISTRICT <br /> AT N: UNDERGROUND TANK PROGRAM <br /> P' O• BOX 2009 <br /> S'TOq(7ON, CA 95202 <br />