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SAN JOAQ�2N LOCAL Fr�ar . I'H•DISTF22<Z7r <br /> UNDERGROUND TANK DISPOSITION TRACKING RENRD <br /> xssxxsx*t*tttxtstxtxsxxsss*xxxxxxsxxxxxxsxxsxsxxxsxxsxzxxxxsxxsxx**xx*xx**stxt**xtxttsxsxxz <br /> SECTICN 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, Mtj holderMrmlt w1th numm-bgr noted belowf <br /> ensuring that this form is completed and returned, 1 <br /> r•_ fil) <br /> FACILITY NAME: ���/� Of Esca/on 6oy�crafia, Yrs/ ��ekFACILITY ADDRESS <br /> TANK ID 939- - S I �in/( No, /, GGnlPaa/P11 {uP/ ° ._7,. . fid <br /> xxxxxxxs*x********xx*zsxtxxxxxxxtsxxzxxxxxx*x*xx*xx**x*szxxsxxxxxs:txxxsxszsxstxxststxxssxxs <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_�i� FC�i1iPM�lUT �u'iCc <br /> Address: �A 1 (11 <br /> Zip: Sa r <br /> Phone#: 7 <br /> Telephone: ( ) Date Tank Removed <br /> xxzxzxxxsxtxxxzxtzxszzzsxxxxxxxxzxxxxxxxxzxzsxtxxzszszsxxxsxssxxxxzzxx*xx*****s**x*szsrxxxs <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Refineries Service <br /> Address: 1331 N.Hw.y 33 P 0 Box 1171 Patterson CA <br /> • Zip: <br /> Fhone#: 298 892-6742 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved ma as ma be regulated by Department of Health Services. <br /> SI <br /> sxs*xssxzxxx s xzxxxxxxxxxxxszxzzxzxzzz�zxz�,EcxAND <br /> xzxTITLE <br /> sxsxxzxzxxzsztxssszxxszsxsxsszsxxxss <br /> SECTION 4 - o be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xxxsxtzxtxxsxszzssxxsxxxxszxzszstzzsxxxzxxxxxxszzz,exzxztxxzsxxzzszsxxxzzszxzxzxzxxsxxxxssxx <br /> EH 13 049 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROCRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />