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SAN JOAOU- 1W LC CJii. H MAX.T`f I STRICT - <br /> _Ca <br /> TANK DIS' 11]IW TRACKING R Rp <br /> ,#ECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> fixed vith its site identification number. The Tracking sheet is to be returned to San <br /> aquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility., <br /> ensuXing that this 1213 1A-a=let%L&A-xet"ned. <br /> ' FACILITY NAME: RV, <br /> FACILITY ADDRESS: 2 A-TT _E M LA r!c, L00 i f� . <br /> ' TANK ID #39- <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: b <br /> I <br /> Address: <br /> ZS <br /> Phone i: -5- - 3 <br /> Telephone: .` _ Z 1 7653 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: p <br /> Address: 63) W. <br /> Zip: <br /> P -) CA Phone#: - <br /> Authorized representative of contractor certifies by signing belov 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 /> c i l ity Name ��`C\CsJ �j- <br /> o�v Cie <br /> Address: 3 V) LIE <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Cif*23 049 12/88 <br /> LING INSTRUCTIONS: FCLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> ' STOCKTON, CA 95202 <br /> r <br />