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SAN J C►A.QUI L® H�AL0 L?I ST'F2I C'I° <br />UNDERGROUND TANK DISPOSITION TRACKING REMRD <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 uermitt with number noted below is responsible for <br />ensuring that this�fform is completed and returned. <br />FACILITY NAME: /�'/lL/T�1�`� ��„% CAGI�'!/Z /7"�,L <br />FACILITY ADDRESS: �t�G1� �'i�,�'©�% ,®� !� ,���°-�c� �-��►/ <br />TANK ID 039-_,,,,L?3 _2� - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: PG0 .65!2X � A2M O W-. 65 , Zi e;;,_ <br />Phone# <br />Telephone: ( ) �'a I-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 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 />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 LOCALHEALTH <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. • BOX 2009 <br />STOCKTON,95202 <br />