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SAN ,70A0*1_T LOCAT• HEAL'T'H •S STR1 CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> 's 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: (,0Z,4-j1) T4�f} rl rP7S <br /> ' FACILITY ADDRESS: �0�7 /T <br /> TANK ID 139- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: IV STGZ��� . 7I1 <br /> Address: 7 3 .� I P O / �n 1)-f + ✓� r T r7c k rn �i 0(,7- Zip: 5 n7 <br /> Phone#: <br /> Telephone: (2�) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: �7G"T+.J /✓1 G;Zt l7 �=G1 <br /> Address: �-�3� T_ P� oo r , n Zip: oz0 <br /> Phone#: CT <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 /> *xx**x*x*x**xx********x*#•*xk***x***xk*****x****xxx******x**************x**********k**x*3*3* <br /> SECTION 9 - 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 /> EH 23 099 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 /> STOCKTON, CA 95202 <br />