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1 <br /> ��LV JGAQLII N LC�GAI� HEPaLTH I7� S'TRI GT <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 clays of acceptance of the tank by disposal or <br /> recycling facility. The holder of the pgrmit with number noted below is res nsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID 939-__/r - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: - 0 C <br /> Address: : <br /> 7 L Phone#zip <br /> �{3 — <br /> Telephone: ( C>t ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: L ) <br /> Zi <br /> Address: © Phone#• U <br /> Authorizer) 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 Name <br /> Zip: <br /> Address: Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <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 /> STOCKTON, CA 95202 <br />