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SAN �lOAQUIN LOCAL, I-IF21T. <br /> TH DISTRICT <br /> "'DERGROUND TAMC DISPOSITION TRACKING RDOORD <br /> SECTION 1 - The San Joaq.11n 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. Tile holder of th <br /> ens <br /> rormlt Wlth h tmF>oC h0 d 1 V la r ann It.t <br /> m ,s com :ted aetu <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID 139- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> rN <br /> Tank Removal Contractor: S S <br /> Address: <br /> � Zipi c� <br /> � � Q 7 / Phonels p _ <br /> TelephonesDate Tank Removed: <br /> ####*####*######*### <br /> SECTION 3 -To be filled out. by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ,P 1/ ( 'n C � (�/C_ <br /> Address: <br /> Zip: a <br /> Authorized representative C)f contractor certifies by signing below that <br /> r <br /> decontaminated in an approved manner as may tthe tank has been <br /> h _.. <br /> Y be regulated by Department <br /> of health Services. <br /> CN*71M**AxDx#,tax#*#**###*##*#***#x####*#*####!####*## <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility t <br /> _y accept,ng tank. <br /> Facility Name L <br /> Address: - <br /> Zip: <br /> Date Tank Received: Phonet: <br /> AVP ORI ED SIGNASAND p <br /> ###########*##*#########!#*##**#***###**#****##�t TITLE <br /> Ell Eli 23 049 12/88 <br /> MAILING INSTR 757 <br /> UGTIONSs FOLD IN-HALF AND STAPLE. ����• <br /> P03 ?E/1�r <br /> SAN JOAQUIN LOCA(. HE AFFIX <br /> AFFIX PROPER <br /> DISTRICT SFR F3 lr y <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOQ(TON� CA .95202 <br />