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SAN JC?7!LQU1 N LU(aAT-, HEALTH DY STE2= CT <br /> - UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> C <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 rmit with number noted below is res risible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: <br /> FACILITY ADDRESS:` <br /> TANK ID 939-- �aK <br /> - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: r V ,'} r0 n , C G __ <br /> Address: 0, B Zip: <br /> 7 <br /> Phone#: <br /> Telephone: (20!? }_ 9 / — ,Sf Date Tank Removed: <br /> ��* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Y l 5 O r! 5 <br /> Address: / 5.q14? .a _Zi <br /> Phone -v <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 4 - 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 23 049 12/68 <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. SOX 2009 <br /> STOCKTON, CA 95202 <br />