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TH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SWrION 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 iolder of the r 1 wi <br /> sur n t t is f m is com leted a re u noted w ° <br /> FACILITY NAME: <br /> FACILITY ADDRESS: /S3 7 <br /> TANK ID 139- .7- 5 - <br /> SECTION - 2 - To be Filled out by tank removal contractor: <br /> Tank Removal Contractor: 1 S > > 1 <br /> Address: i <br /> Zip; <br /> Phone#• <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: 1 <br /> Address: <br /> Zip. <br /> Phoned: g <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as pray be regulated by Department of Health Services. <br /> i <br /> ------------ <br /> l <br /> SIGNA AND TITLC <br /> SECTION 9 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: <br /> �} C <br /> Phoned: a4 <br /> Date Tank Reeei ed: <br /> { <br /> WILED SIGNATURE AND TI <br /> Eli 23 049 12/88 4�f <br /> 14AI LI NG INSTRUCTIONS: FOLD IN HALF AND STAPLE. � '-. ����`! '� <br /> AI''FIX PROPER POSTAGEf lr <br /> SAN .JOAQUIN LOCAL F&ALTH DISTRICT <br /> ATM UNDIMMOUND TANK PROC tAM ? <br /> P. 0. BOX 2009 <br /> STOCCTON, CA 95202 f;,C)j. r.� <br /> 4;_JVTAL <br /> ;tAL%r- <br />