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SAN 70 ��� LOCP,I� HEALTH � STE2=CT } <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> I <br /> xxxzxx*###*z*#***x***xzxx*x*x*#x*x*********x**xx***x**x*x*x**x*x*x*xxxxx*x**x*zxx*z*##x##** <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: Ll <br /> TANK ID Y39-a3 7 <br /> *x*x#*#**#**z*#x*z**z***xxx**zx**x*zxxz*x*xx*xx*x**x***xx*x**x****x*x**z**x*xxx**x******xxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 1v N mr TT 2 ISG 2 06�L / VC <br /> Address: �-�� � � � ^ on lit ✓Q �TOc krn v C'Ff Zip: 05 c5 <br /> Phone#: <br /> Telephone: !;�W Date Tank Removed: <br /> *zz#z*##*z*x#*z* zz*z*z**xxx***zxx*xx**z*z**z*xxxx**z*xx*****xz****xx*x*xx*x*xx*x*zzzz**zxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �FZ��'//�G r,Cp <br /> Address: �-73� T Qp 1� r i/IP_KrD�/ �'A Zip: <br /> Phone#: 2-09 <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 /> zzxzzzzz##z*x*zxzzzzzzzzz*xxz*xzz*xzxxz*xz*xxz**x*xxz*xz**x**xzxzzz*z*xx*xz*xz**zzz*xzzxxx* <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: Zip' <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xxx*#x*xz#zz#zz*x*z*x*zzxx**xx*x**z****x**xx******x**z*xzx**x******xxx**x****xx**xzz*x***zx <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STO KTON, CA 95202 <br />