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1 <br /> S.ANf J"OAQU 3=N L O C"'".AL �,z��T H D= STRICT • <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: �,LL_ 6ea.\I1Ge. 6 TL'``TI W -' <br /> FACILITY ADDRESS: <br /> TANK ID ,#39- - <br /> �*���iK*�������*i;pis*��*�������*�*�*���*���**�*�****��c�r��*•��c*�r�r��*�c�x��r�r��r*�r���r��r*��*�r*�r�c��c�c� <br /> SECTION. - 2 - To be filled out '.by tank removal contr=actor: <br /> Tank Removal Contractor: l�.+Z Mi��- 1•���2r-t�+JS� C ti; `TGS -- -- <br /> Address: ?5(n1-. rzia ,�.�/� Zip: <br /> Phone#: Lql ) 931- 51 <br /> Telephone : { } 20 Lb I Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor: A%2"ea- 1-bet-x O A Ssc y-4A-res <br /> Address: 3rzf A',/Ls Zip: <145z7G <br /> 1+�1a.4>Ju-r G22 IL CA Phone#: (A15) g3�Z- ►���) <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 Servic=es. <br /> SIGNATURE AND TITLE. . <br /> :k*ic;kirkk9k*�t�C*�k���C;K.3k'#icic�ir�e**fir*i;i;�f��k**7k**:k�;�C**.�e'��CiC#Jrie:%�:�icx*7c�t*i;ye�*ic•kzxi;**x*ie�c ie�ris* k*�'�*��sis�ys�it <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 L✓Q1 ,a �W C, <br /> Address: - SS � � �1VD zip: 94a2i <br /> MlPhone# : MI S) 23S-095 <br /> Date. Tank Received : <br /> AUTHORIZED SIGNATURE r-ND TITLE <br /> *ir�kF****:kiC*irir�k�k:k**�r�Y�:r�tir**kik*7r*k*5Y***5tir***rk*�k**�k�r*�Xx�e3tir** 4*iC*�k�ak�:Xitxxiric�'*irk*�[*irk•**iC�xirsk** <br /> 511 23 049 12/88 <br /> MAILING INSTRUCTIONS: .FOLD IN HALF AND STAPLE. :T-FIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TA-r K PROGRAM <br />