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SAN a OAQUI N LOCAL HEALTH/ DISTRICT <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. Tie holder of the permit with number noted below is responsible for <br /> ensuring that this <br /> �� form is gompleted and returned, <br /> FACILITY NAME:_n))C) !� <br /> FACILITY ADDRESS:_/1(611 ` S(­�u <br /> TANK ID 139- - <br /> SECTION - 2 - To be filled out by tank removal co Tactor: <br /> Tank Removal Contractor: oj&� <br /> o / <br /> Address: y3 3 At. 00(-V V, 3/TZ-1,4 Zip: <br /> Phone#: .cif <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: 3 Ab /wood 6S1F y 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 rof the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name /�rl?iQ�`( 0,12 /Z'?I'v / <br /> T <br /> Address: E?2 S 5 ,�7 l���u� h Zip: ql 7( f <br /> Phone#: <br /> Date Tank Received: <br /> AU'T'HORIZED SIGNATURE AND TITLE <br /> E11 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />