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SAN .?DAQ'LJIN T_,0aAZj k AT.rrH DI STf?.I CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />CTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />4 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 holder of the permit with number mooted bglow Is responsible for <br />ensuring that this formic comaleted and returned. <br />FACILITY NAME: cern �;��;���✓v �cx(; �_ a �•�tr�� <br />r FACILITY ADDRESS: <br />% Ci C' k_'70,' GAS c�—C� <br />.�% <br />TANK ID 139- <br />SDCTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: k7ze-Slfv'te-< <br />Address: /V6, C-4 Zip: <br />Phone# :'1/— 9S3 � <br />"` • <br />Telephone: (�) 16i V=— Si` J ��� Date Tank Removed <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Wress: a,4& AAO��QiLli7 Zip: 9 <br />c Phone#: <br />Authorized repre ntati o contractor certifies by signing below that the tank has been <br />decontamina! i a .ov dman r as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <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 />x 'Address.- Zip: <br /><< Phone # : <br />A, <br />Dene Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12188 <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 />