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0 <br />6 <br />SAN COAQXjIN LC]C'.,AL. 143T_ r TH DISTRIC`r <br />UNDERGROUND TAMC 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 District 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-� - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor i j �C (7F Nj C <br />Address: �7 j �- �. L� Lj C VA Zip: �i_ > <br />Phone# <br />Telephone: i ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />Phone#: <br />ip: <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 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 - <br />Address: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />E!! 23 049 1.2/88 <br />Phone#: <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPa� POSTAGE, <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN : UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />mcyucv, CA 95202 <br />ip: <br />