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MAR <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />ENVIRONMENTAL HEALTH <br />SECTION 1 - The San Joaquin Local Health District's TrackingSh t�w�l c b any`�each tank <br />� <br />affixed with its site identification number. The Tracking Sheet" e'�to be turned'to San <br />Joaquin Local Health District within 30 days of acceptance of the or <br />recycling <br />recycling facility. The holder of the hermit with number noted belo4<1.;�`rasponsi le for <br />ensuring that this form is com2leted and returned. --s y, .. <br />FACILITY NAME: Uteri OGF�1p.- _��- . (�, 0 rj <br />FACILITY ADDRESS: <br />TANK ID #39- <br />*ik�7ryk�k*sY**�t�Yxcit*�*�c�yk*fir*Yc�t*ic* <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: dal F1a>✓.. GE)►�iST(ON <br />Address: 1-710 Zi : G13612 <br />-A-- t3 _ Phone#: �So�;) 59 -55jW <br />j <br />Telephone: t ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Address: t f ! O e-141zip: ?j �a f G.. <br />L L 4 41!�8 13 Phone# : ScS� <br />Authorized representative of contractor certifies by signing below that the ta�*„`has been <br />decontaminated in an//appro manner as may be regulated by Department of Health <br />`Services. <br />' STATURE AND TITLE <br />nSECTION 4 - To be filled o` signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />Date Tank Rece <br />Zip: <br />Phone#: (84 <br />AUTHORIMED SIGNATURE AN1f TITLE <br />ic�kstic*irir*�tir�*st*�***iris*ic*�**��kis�Y�tic*icir�ici:*ic*ir*�**��tit*����**7c�k7c�i*icir**ic�t�***��**iri��icicicic9kicir�xxx�x** <br />Eli 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 />