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SAN 70AQLJI N LOCAI� HEAlllrrH DI STE2I CT <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 of the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: a 1 ��A Cti\G 1l 1 (l 1A 4' n hi C_ l f1 0 <br /> FACILITY ADDRESS: 3 ,_ <br /> TANK ID #39- 1q5--7 <br /> - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> a <br /> Address: Py k `oC\ C� Phone#Zip. �- <br /> Telephone: ( �� ) O �- I a Date Tank Removed: , C�- Q l + C' 1 -�1 - ✓ <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: uo e- a O.� , Lo e,` l c n 4- <br /> Address: <br /> 4-Address: P 0 �Q C� VA t C' km�am _Zip: <br /> r c-c'1 �N ;c.k �n�-� C _Phone#: �ZlH - <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 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility NamejIc <br /> ,,n �CdC>� LA�c� �C� C ✓1 <br /> Address: P C) c off 4 Zip: <br /> Le.9-( , - A- Phone#: <br /> Date Tank Received:— <br /> AUTHORIZED SIGNATURE AND TITLE <br /> E11 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 /> STOcx7,ON, CA 95202 <br />