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itt .a <br /> TANK DISPOSITION TRACKING RECORD <br /> x�xxxxxxxxx**xxx*�*x*xxxxx�*xx**xx��x*x*rt*xrt*��x*x***xx�s**xxx**sxx*��*x*****x+t*xx�cx�*xxx*ir <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each <br /> 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 b disposal recycling facility. Y or <br /> ur t or 1 w <br /> e <br /> FACILITY NAME: <br /> FACILITY ADDRESS- <br /> TANK ID 039- / -7 S <br /> SECTION -- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 1 <br /> Address: Arxe'L Zip: 1r�yA <br /> Telephone: Date Tank Removed: <br /> SECTION 3 <br /> xxx*xx*xx�*x�x**x�*x�xxtank �r*x*****xxxxx <br /> --To be fi7Jed out by contractor "decontaminating <br /> Tank Decontamination" Contractor: Ale 117?,t <br /> - I <br /> Address: r F c `'tee ✓,Cl/� I <br /> 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 <br /> by Department,''of Health Services. <br /> SIGNATURE AND TITLE <br /> *�**xx•*�*****x******xx****��**�x***�**�x**�***xx**�***xx��x*****�xx***�**x********x**x�x*xa i <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment <br /> storage, or disposal facility accepting tank. <br /> • I <br /> Facility Name <br /> Address: <br /> /� c S�c/x��He.�j"Q► Zip: <br /> Phone#: si - 0 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTACE, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UN=GROUND TANK PROGRAM <br /> P. O. Box 2009 <br /> STOCKT Nr:Chi 95202 n . <br /> • 'V <br /> } <br /> 'f <br />