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3UL - 20 - 8_9 W ETA 1 4 15 MOORE PETROLEl '" <br /> SAN JOAQUIN LpCPT- HEALTH DISTRICT <br /> UNDERGROUND TAMC DISPOSITION TRACKING RECORD <br /> SDCrioN 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 holderhe permit with—n-umbe noteo below is respDnsiblef r <br /> ensuring that this form Is completed and retur-nO <br /> FACILITY NAME: '� 'L <br /> FACILITY ADDPMS: )3 9 9 r YO Li -"I 17L ft>= . /17/7v C.A . MI5 3 -5 C-- <br /> TANK ID 0 39 - <br /> zzzz*******##z******�*#*x********#zzz*****##zxzxa*******�******t�#**z�**�txrr****#****#*#x*�tz <br /> SDCTION - 2 - To be filled out by tank removal contractor, <br /> Tank Removal Contractor: <br /> Address: zip: <br /> Phone M: a a 1) 7e t- �! <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractors <br /> Address: Zip' <br /> Phone#: <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 /> 1t##*#####iF**###**•kRzz*zit*z!r*******R*#*****!r**,k#it##z�txz•kz*7�*x•z*x****ltkxk******ic************* <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 --—• <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ATFIX PROPFR POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMOROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOt}Cm4l CA 95202 <br />