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Sl3L-7 J"C7AQU_LLV T.Oci 1 HEALTH DI STR� CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RDUORD <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 responsible for <br /> ensuring that this form. is completed and returned. <br /> FACILITY NAME; L1_ r ►2�1►G S�T�TI(3►- <br /> FACILITY ADDRESS: <br /> TANK ID ,#39- <br /> SECTION. - 2 -- To be filled out by tank removal contractor: <br /> r <br /> Tank Removal Contractor:— ms A2rz <br /> Address. }x(01= 3r�� �y!✓ Zip; <br /> .c)4,g <br /> Cego Y . C/N Phone#: I 3 -S3S[al <br /> Telephone ( } ` 3� 5U I Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination1° Contractor: t,4C3rz-V%,j.1 .� <br /> Address: 'Zip: C)459( <br /> l�tipluu-� �2�ek SGA Phone#: S 3-1- SSv? <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 /> _ S I(MATURE AND T I TLE <br /> SECTION 9 -- To be- fi]led out and signed by an authorized represnntative of the treatment, <br /> storage, or disposal: facility accepting tank. <br /> F'acilitY° Name C_ -- <br /> Address: ' S~5 �P. ►2 �VD Zip: <br /> 1644 Majwl(>_ CA <br /> Phone#: M z3'S- X93 <br /> Date Tank Received : <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *��c*����*�k***��*�kYs�c***��������***ic*****���������r�*�kV����*****���*�•r.xz�Cic:r*����c������e�*�kx�rak�* <br /> Ell 22 049 12/8.8 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. r�IFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br />