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0 <br />SAW ao®&Qui L0H T°H 01 STRICT' <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 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 uermit with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME•�}jc' <br />FACILITY ADDRESS:7 � <br />TANK ID 039- /!___3_,_,_- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor:_���L�, <br />Address: - to '66K 22 AM ©ter 6�5 `"'!l���O 9'c� <br />Phone#Z�¢ <br />Telephone: (�) r%� y" y33y Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: Zip: <br />Phone#: <br />Authorized representative of contractor certifies by signing below 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 />Facility Name <br />Address: Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />UNDERGROUND PROGRAM <br />P. a BOX 2009 <br />STOCKTONr <br />