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�.AN .JOAQUZ,N L,p�L I.�J'1'I� Dz S'I'RT C <br />UNDERGROUND TANK DISPOSITION TRACKING RDCORp <br />SECTION'1•- The San. Joaquin Local Health Districtls <br />affixed with its site identification numbe Tracking Sheet will accompany each tank <br />Joaquin Local Health District within 30 days ofTacceptancehe gofhthe tankob <br />recycling facilitosal or <br />be returned to San <br />Y• T e holder of the rmit with number noted helow is aesponsible for <br />P.Ilsurq.that this form is Com leted and returned._ <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />TANK ID 139- 11-7 <br />******it**�t***it�t*�r**�k***it**************�F * **y <br />SECTION. -' 2 ******�GC�� <br />- To be.filled Out. !by tank removal contractor: <br />Tank Removal Contractor: <br />Address. D5W V;17 <br />--Zip: _82� <br />Telephone: <br />Phone 0: 9�( 119gD <br />************** ************** ********** ***Tank Removed <br />SECTION 3 -To be filled out by contractor "decon.taminating tank 'I: <br />Tank be <br />Contractor: <br />Address: 2 ttlp •,418 <br />Pp: e7l <br />hone1Z19i 2� <br />Authorized representative of contractor certifies b s• - LP � 199c,> <br />decontaminated in an .approved manner as Y signing below that the tank has been <br />may be regulated by Department of Health Services, <br />TORE 'AND TITLE <br />SECTION 4 - To befilled •but and signed b <br />'storage, or disposala an authorized represnetative•of the treatment <br />facility accepting tank. <br />Fac' <br />ility Name <br />. - • -: '1'. �IC.�-SL�C,f . <br />Address. __ E• 2s5 • <br />�eNF la,ur� Ca zip: <br />Date Tank Received: Phone#: <br />�Fi3 X23 =139 <br />TURF AND TITLE <br />EI! 23 049 12188 <br />MAILING I INSTRUCTIONS:*********************x**r* <br />FOLD IN .HALF. AND STAPLE. <br />AM PROPER POSTAGE. <br />-SAN JOAQurN <br />[A-:. HEALTH DISTRICT <br />ATTN: • UNDLI2GWMD TANK PROGRAM <br />80X 2009 <br />'Toter CA 9.5202 <br />