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15 M O O R E P E T R O L E I P _ 9 P <br /> SAN J oAaLj I N LOC A T. HEAI-TF-i DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING REOQRD <br /> SEX.TION 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 2crmit with number ed below is resnons able for <br /> ensur na tha rm is completed <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 1399 `(USS r'1 1-11L fy1=• /�I/ t►4 CA . 95 33 c <br /> TANK ID <br /> SQCTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:- <br /> Address: <br /> zip: <br /> Phone o y/ -3,6f <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor; <br /> Address: Zip: <br /> Phoney: <br /> Authori2P4 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 /> 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 SIcNATURE AND TITLE <br /> E!1 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 /> STOCKTON, CA 95202 <br />