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SAk-T Z70AQX_T1k4 T.,0C_A3r_, HMAr-arrH DXS7TZ1(-_"rr <br />I Z 10" 6 OF, Me" 11) N*c* 40 0 fi; 5- ,,14 Z RE v Draw v <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 t_hg 2grMit with number noted Leglow is-re§20nsiblg for <br />em—ur-inq that this form is comDleted and retur*tntf. ' <br />FACILITYNAME:_ i6AA/te- 6F <br />5TVC7,6-WA) <br />_J_6_r FVC1-- <br />7AWK <br />FACILITY ADDRESS: 14"G�Ak_# <br />-zosr <br />5't v_varlzy <br />5rveA-.WAJ in&-rreo <br />TANK ID 039- <br />FA;%1W AVINIA-W <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: S671 63n i -C) (�O'LZZ09X 77e,1.1 <br />v <br />'F20 57. 57 - <br />Address: zip: <br />Phone#': T-Zf— 72 - <br />Telephone: (_4 c" 7 1 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: i_o Co o g,-9 ZZeA.1 <br />Address: Awjr,-�t cf;p_) 5T-4 ',�MCK744J C401 Zip: <br />Phone#: <br />Authorized representative of contractor certifies by signing below that the tank has •-- <br />r- • -• <br />eedecontaminated in an approved manner as may be regulated by Department of Health Services. <br />A*X19 Xxxx WWW* <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 k1 Ai CAW AD <br />Address: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />