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• <br />SAN aa2!kQTj1 N Loc�°Ar . HEA�TH D1 STRI (=r <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 Distract within 30 days of acceptance of the tank by disposal or <br />recycling facility. The holder of the permit with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID #39- /X65 <br />- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:1 <br />Address: <.A Zip. <br />Phone#: �'�`• - . i <br />Telephone: (� ) Date Tank Removed: <br />SECTION 3 --To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />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 TITLI <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 />Address: <br />Date Tank Received: <br />Zip: <br />Phone#: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAM JOAQUIN LOCAL HEALTH DISTRICT <br />ATTR: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />