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1 <br /> SAN 0 OAQU I N LOCAL HF=.�1L'I'H D 2 S TR I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> Tr <br /> ECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> ffixed with its site identification number. The Tracking Sheet is to be returned to San <br /> oaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> ecycling 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: �,Q/�'� 710 A-) <br /> FACILITY ADDRESS: 2/5- GtJ . /y,4//(/ /21"Oy&I <br /> TANK ID #39- IV7Y - O/ [ 3-4U <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> This tank was removed and sold several years ago to <br /> Address: rouwer, 3841 Exception P1 . , Escondido, _ <br /> Tt is now P: <br /> on their ranch on MerveAve, dip. <br /> Phone#: <br /> Merced County, we presume it is curren y eing used <br /> Telephone: d i e s e l) e. " A Da moved: <br /> SECTION 3 -To be filled out by contractor "d&ontam ating tank": <br /> Tank Decontamination" Contractor: <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 /> 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. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />