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HF_A Y T, <br /> Tr D 2 S-Ira:[Crr <br /> !/ tIH M—\-,JM TAW DISPOSITION TRACKING R RD <br />/hII1tIIIIIIIIIIIIIIIItSIIIIIIIIftIIs7ltIIltIIhftIIIIAitAttAltAAAttIIAAftAAAAAAIIAAAAAALrAAAAAft�SA1tQAIIltftA7tfrAAltt�kIIII}�IIII*IIIIIIAAII�� <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will a <br /> affixed lith its site identification number. The Tracking sheet is to be returned o Sanach e <br /> Joaquin Local health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility.,- The holder ofhe aermit With nt?m�r natA h�1n� �_ <br /> kwurina that this artapQ 1 <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 4 �R F �^iTL� rn f LAN t�oO (�r4 <br /> TANK ID 1139-�L.L_-__.- ��. <br /> II7YIIIIRIIIIttAttrtIIAEtcIIIIIIIIRIIAitIItftft# IIII'IIIIAtt1tIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIAIIAAIIIIIIAftAlYfsAIIAaitAAAitttfrStIIttAhAAaAYtitirx.: <br /> SECTION - 2 - To be filled out �by tarn recoval contractor: <br /> Tank Removal Contractor:- <br /> Address: <br /> ontractor:_Address: <br /> Phone 0 <br /> Telephone: X09 ZLI-9053 _Da <br /> te Tank Removed: <br /> tthAttttttAAYtYtYttYttirQitirftAttttAtYttitttkt�hfTttAA'AAttAfiftAt'ttsttttAAtYAtrftII�QQ1cAAIIitYiAQAYtYritAYsRAhlrAirhiticttJtttIIttYYAltAfrlrzAt:; <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: m( O <br /> Address: �� <br /> PhoneD: <br /> zU-9l�� <br /> Authorized representative of contractor certifies by signing belov that the tank has been <br /> decontaminated in an approvedmaim; as may be regulated by Department of Health Services. <br /> AYtAAltitttitAAitAAAAftAtttss2AAitAftAAA�A�tAfi�$LtAA'IIGNRAR7WEQAMAggTITLE <br /> AAftAAAAQAIIttYtAitftAAAttAftQitttQitAAAAfttrhttttx <br /> SECTION 9 - To be filled out and signed by an authorized re <br /> acoe ti Presr�etative of the treatment, <br /> storage, or disposal facility, P n9 tank. <br /> Facility Nam �`��sJ �v djj <br /> Address: i& - f <br /> Zip: -' <br /> Phone o: <br /> Date Tank Received: <br /> ttIIIIAIIIItYAitAIIttxritAASfStttltAAittt}tIIAitAAAAAUrAAZED <br /> AIIAASIGNATURE <br /> AAAND <br /> AAAATITLE <br /> AAAftAAAAYrittthAfrAirAAttAttAStftttAA7tAxk <br /> EH 23 049 12190 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JQAQUIN LOCAL HEALTH DISTRICT <br /> ATIN: UNDERGROUND TANK PROGRAM <br />! P• a. BOX 2009 <br /> ETON, CA 95202 <br />