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SAN .J OAQU S N L O r 2)LT1 14E12 L rr H D 2 S`I'R SCT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ******************************************************************************************* <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: 4 9.60 0207(o <br /> FACILITY ADDRESS: &0 f�_fQS7 L-517 _r,N,dN C.14P - LOP) 10k UNI. <br /> TANK ID #39- <br /> SECTION <br /> 39-SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:- E/LLV Lk <br /> Address: X10(9( S ff%dPM1 (31-y� (.J. 5 ��1�1 �tiJ �C� c!a • Zip: <br /> Phone#: 17/(, -37Z - (1�KS <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 5,cLW R <br /> Address: Sdme- Zip: <br /> Phone#: <br /> Authorized representative of contractor certifies by signing below tM t 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 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 /> ******************************************************************************************* <br /> Ell 23 049 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 /> STOCKTON, CA 95202 <br />