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SAI .70A0FIN I..00,ATI HF�.r.•r Dlsz'R�cr <br /> UNDERGROUND TANK DISPOSITION TRACING RDOORD <br /> xx**RRRxRRRRRxRR**x*R*R****fi**Rfi****xx**xfi***x*xfi***Rfifi*fi*RRxfi*fiRx*fi*fi*R****fifi**RfiR**RR*x*R <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 wit nw+mer noted below 14 r sporQ hie for <br /> ensuring that this forla ills CompigtKI and returned <br /> FACILITY NAME: m r6 <br /> FACILITY ADDRESS: a� &U1H 14/\/L a Q 4i/o 10 C A - C/S 3 �) u <br /> TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:Sl=McO <br /> Address: L-tL Wl %Tc:ffiz- 2SP . P eCAL,11 A- Zip: <br /> Phone#: <br /> Te lephone: ( tea ) a� - �I 5 3 Date Tank Removed: <br /> x*xfiRRfi**R*Rxx***R**Rxxx***xfifi******fi*Rfifi*RRx**fi**x***RRRx**fixfi****R***xxfix*R*x**xx***x**** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: S /rkp <br /> Address: L_ �\ W , R�, / \�� s�� A Zip: 95�� <br /> Phone#: r�9-— �r <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 /> *x*fi***fi**fi***fifififiRR***R**xxRRRxR**fifiR**fi*x***Rfi*****fi**RR*fi**x***R**fifix*fi***fi*fifi****x***** <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 SCFn�p <br /> Address: _y3� �T� �� . /�c 1,c� 6 ,q- Zip: <br /> Phone#: :�YJI- y q r Z <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 13 049 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 /> STOCC1XV, CA 952C2 <br />