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SAN JOAQU k4 LOCAL g- F=_ TH D2 STF2=CT <br /> UNDERGROUND TANK DISPOSITION TRACKING REoopD <br /> x*XXX*x*******X***x*****X**X**X**XX*XXX*XX**X**X**XXXXXXX*x**x**x******Xx**x*xX*X**xX*XX*** <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: (AJAVP044�ryc / <br /> FACILITY ADDRESS: t /,14Al2T"l4 CYocff7'cA/ rif <br /> TANK ID #39- L � y <br /> *x**********XX*X**XX*X*XXX***X*XX******X**XX*X*XX********X*XX**X*X**X****XX***zz*z**XX*xX** <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_jF/f (5.vr 1 ierje1 a <br /> Address: G /Zrr 42GLOC M'rCA/ Cj Zip: <br /> Phone#: Y6 - 2000 <br /> Telephone: ( c9)__ YL-5- 2o'00 Date Tank Removed <br /> X****zX**X*****X****X*xXX*XX*******XX*XX****XX****XXX**X*****z***X***k*******zx**xX*z*X*XXX <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: _i&IC Fi1e/*£Fie1N6 <br /> Address: n, G 2� ;2r. 76 5'rc,rL?-c Al C'�l Zip: _9��,y <br /> Phone#: ycs aooa <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 /> x*z****x*z*xxxxXzz**zXzxX*xzz*x*xzz*X*x*x*Xx*XXz**zxxzxXzx**X*xX*X*x*xxXzx*XX***zX*zX**xx*x <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: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *X*k*X*X*X*********X*X***X******zX*XXX*XX*XXX**X*******XXX**X*X*********xx*zX*x***kxX**X*xX <br /> Ell 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 />