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Y <br /> ORDUNDERMAWD TANK DISPOSITION TRACKING R <br /> xx:xzz::z:xtzztzzztttzxzzzxtzttzxtzztxzxxxtxtzzzztxtxxxxxztxzxxzxtzzzxzzzzzztztttttzxztzxzt <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 <br /> � is completed and returned. <br /> / <br /> FACILITY NAME: I � l a Y f e ccs ` /t anrc 1 �-e_ <br /> FACILITY ADDRESS: 10, 90 L,. +Q— <br /> TANK ID #39- 1 (_ 5_(� - 0� <br /> xzxxzxxxzxxxzzzzxtzzzzxz:ztxzzxt::zxxxzzzztxztttxxzzzxztzzzzzxzzzzxzzztzzzzzzzzzzzzztzzzzzz <br /> SECTION - 2 - To be filled ou(t� by tank removal contractor: <br /> Tank Removal Contractor: ' `=TTtzft,vmsrF� PCS-lL <br /> rc CEIPc'L <br /> Address: 21-7 1 n 0 (1A 12 r � ) Zip: <br /> Phone#: <br /> Telephone: ( ) Date Tank Removed: <br /> xzzzzzzzzzzzzzzzzzzzzzzzzztzzzzzzxzzztzxzzzzzzzxztzzzzzzzzzzzzzzztzzzzttzzzzzzxzzzzzzzzzzzz <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: V)Ukm 1 Address: r„ -- <br /> Zip: <br /> Phone#: <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 /> 63 SIGNATURE AND TITLE <br /> j:�:t::t:tz:zxxztzxzx:zxztxzxxzzzzxxzzzxzzzzztzzzzzzzzzzzzzzzzzxzzzzzzzzxz <br /> ( 9�0 <br /> nic4n �( « <br /> �w� <br />