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' SAN aO QUI N LOCALL FfAr 7rH D=SrMj CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District' 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 holdgrof the ucrmit wittLrLLMftr ngtAbelow Ig r25ponsibleor <br /> enguriDg that this f rm is ggagleted and ret ed <br /> FACILITY NAME: <br /> FACILITY ADDRESS: c� �r •y� u 7J�r�. czx /�77 /' <br /> �-.u/ rnfrt <br /> TAMC ID 139- 14(P f - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: an �wr,, GiZ�- tea IL <br /> Address: /o?/ �, z� L�7 .� G� Zip: <br /> Phone#: <br /> Telephone: ( ) Date TankRemoved: <br /> SECTION 3 -To be filled out by contractor "decontam hating tank": <br /> Tank Decontamination" Contractor: <br /> Address: 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 /> k <br /> ' A <br /> SIGNATURE ANDS T TLE <br /> SECTION 4 - To be filled out and signed by an autho ized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AM TITLE <br /> Elf 23 049 1.2/88 r <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE, APFFIX PROPER POSTAGE. <br /> SAN JOAQUIN CACAL HEALTi DISTRICT <br /> ATTN: - UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />