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asxUNDERGROUND TANK DISPOSITION TRACKING RECORD <br />r} a <br />**ir�Eik***'#*�k*xxx�t*xx�t**xxxx�k*9t�txxxxxxxxx�cxx*�kxx�ri�xxxxxxxxxxxxxxx*xx*x�r�irx*a��kxxx*xxx*x*�Yr**�tx* <br />SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br />affixed with its site identification number. The Tracking Sh t,is be,(kurned to San <br />Joaquin Local Health District within 30 days of acceptance of the ta, d poral or <br />recycling facility. The holder of the 2CrMit with number n ted".below is/re4r>ons3ble for <br />ensuring that this form is completed and returned, '°� f ;`' <br />". <br />FACILITY NAME: 0t <br />FACILITY ADDRESS: <br />TANK ID #39- - Q <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: i�E�1�F=A6� GEyii�l� Tt�i' <br />Address: 10 Com' 1�o WL�.� 2t7 �P�k'r=QSF1 ��ii1 �A Z i 9 S16112- <br />►_� G. 413913., _ Phone# : cam) 5� 1-550 <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: 17711Z) <br />zi 9 36(Z <br />#: (So✓ S 8.�-- sl 0 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in ana"approved manner as may be regulated by Department of Health Services. <br />SIGNATURE ') 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 />Facility Name <br />Address: <br />Date Tank Received: <br />{ r— <br />�,®/,e� Zip: <br />Phone#: Cy <br />ALYMORIW `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 />