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�77�""~- -` SAN sOAQU=N LOCP.S# i-iEpTTH I]TSTRICT � ' <br /> UNDERGROUND TAN!{ DISPOSITION TRACKING RBOORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet vill accompany each tank <br /> affixed vith its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District vithin 30 days of acceptance of the tank by disposal or <br /> recycling facility, Mie holder of the pgrmit -withd bel9w o <br /> ensuring that this t4fm,_JS completed�and_r9turned. <br /> FACILITY <br /> f FACILITY ADDRESS: SD , . a <br /> 1.' <br /> TANK ID 139- <br /> SECTION <br /> 39--SECTION - 2 - To be filled out by tank removal contractor: <br /> r 1 <br /> Tank Removal Contractors <br /> AddresstL1 ' u Zip: - 93 ,4.-7 `µ <br /> c Phonel: t r f- 1 <br /> Telephone: ( ) Date Tank Removed: <br /> #**#*******#**** <br /> SE)MON 3 -To be filled out by contractor "decontaminating tank_": <br /> Tank Decontamination" Contractor: ' J <br /> Address: Lard WI - CZips <br /> Phonel: <br /> I' <br /> Authorized[ ed representative of contractor certifies by signing below twit the tank has been <br /> decontaminated in an approved manner as nkay 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 -Cal ' <br /> Address: a v0C. ' Zi 5 3 <br /> 5 <br /> Phone$: <br /> Date Tank Received: <br /> AtYrjjcPkf_z_jc.D SICNATURE AND TITLE <br /> S!! 23 049 12180 <br /> MAILING I NSTRUCrI oNS: FOLD IN HALF AND STAPLE. Ai.FI X pRopER POSTAGE. <br /> SAN JOAUUIN LOCAL IEEALTIt DIS'ITUM <br /> AT H: IINDMGROUND TAMC PROWZAM <br /> P. O. BOX 2009 <br /> STIOCKMIr CA 95202 <br />