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SANT 002NIQ*UIN LOCAL, I- M r.TF-I ;)IS'.I'RI= <br /> UNDk�t41dD TANK DISPOSITION TRACKING R*W <br /> zztxxxx�zzzzxxzzzzzzzzzzzzxzzzzzzzzzzzxzxzxzzzzzxzxxzxxzzxzxxxzxzzxzzzzzzzzzzzzz:zzzzxzzzx� <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 /> enuring that this form is completed and returned. <br /> rACILITY NAME: U�/J" ..S <br /> FACILITY ADDRESS: <br /> TANK ID #39- `��,til�4E 1" — / � �' l7 Ci/ S G'G�/7 ufl7t ` Z� <br /> zzxxzzzzzzxz zzzzzzzzzzzzzxxzzzzxzzxzzxztzzzzxzzxzxzxzzzzzzzzxzzzxzzxxzxzzzzxxi.zzzzxzxxxszz <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ <br /> Address: ��4I`"���1_/ / �� c / �' C !� G t- -s7ov � ZiP. �-� <br /> Phone#;> <br /> Telephone: (��'!_}^_`/" `! '— ✓�`/ -b pate Tank Removed: <br /> xzxkkxxx*is�xxi:xxxxicR*xzx**zxxxxxz*xx*xzxxxx*xxxx�xxx*x*xxxxxx*xxxxxxxzx***xxxxx***xxxx�xx*x <br /> SD 1TN3-TTo, '. L y contractor "decontaminating tank": <br /> TS&§WjHctor: <br /> Address: .� l �e ' /i'r< ✓7jZii C. Zip: <br /> Authorized epresentative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved er as may be regulated by Department of Health Services. <br /> i <br /> SIGN HIJRE, AND TITLE LE <br /> zzzzzzzxzzzz�xzzzx�x:a:txazxtzzzz*xx*zzzzzxzxzzzzzzzzzzzzzzzzzx,rxx,rxxzxzzzzxzzzzz�;zzxzzz*n az* <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 /"A /rl a--IC._ /..i C. v �` Si¢c, iz1,41e : yG <br /> Address: 3��1� j y ; i� ,: :r c $.f c./2.1,1�4fc "j*t Zip; <br /> Phone#: <br /> W— P/A/ -Aff� <br /> Date Tank Received: (,c{ C� 198 9 _ _— <br /> Al3774ORIZED SICNATURF AND TITLE <br /> xxxxft7Fxx'.F:�':dA'xxi[�'Nxx1Fx.t'1FN1txxR:Fxxirrt'XA'xY¢SCxxxil'xxiYxxfixx'Rxt.'t'xxxxx7tA'xxxxxxxxlFxxlF ffx'i xx]Yf'A'x Rt�txRxf'7tX <br /> RH 23 049 12188 <br /> TAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER P I %aldE n� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Jau UU <br /> AWN: UNDERGROUND TANK PROGRAM MAR 161989 <br /> P. 0. BOX 2009 <br /> STOCKTON, Cil 95202 ENVIRONMENTAL HEALTH <br /> PERMIT ISERVICES <br /> r <br />