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S SIV .�OA I N LUC�I� I-1:EAL.'I'F-�I S'T'Ft I C'I' <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 District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder pf the pgrmit with number noted L)qjow I resDonsib e fgr <br /> ensuring that this form i cam leted and returned <br /> FACILITY NAME: <br /> FACILITY ADDRESS: Z, <br /> TANK ID #39- f 1 - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:- J 7e ,J?�Ie /,1'e4. c e- <br /> Address: o.r e /'e C- /'-W11 zip: <br /> / Phone <br /> Telephone, Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: A& ft S7cwi,re e <br /> Address: . �/ - j F ez=C 11,411 7— Zip: <br /> Phone#: �d�Jiy_G <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 !�/Z 64 ,r� - o�ti" L r'" �- ¢y�c-� 7-e- <br /> Address: .7 ,-Jf }�--�.' /� c �y�t'�' Sr c 4.1-*epi c Zip: <br /> Phone#: J� <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EN 23 099 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROVER POSTACM. <br /> SAN JOAQUIN LOCAL HEALTH DIS'T'RICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2005 <br /> STOC KTO[J, CA 95202 <br />