Laserfiche WebLink
Jrui JUAgU M WU iili <br />JOW KHANNA M.D. XP.H. <br />Health Oliku • :: <br />P.O. Bus •(1601 Bart Harckm Avwue) • Uucluurr, 6ak" 95201 <br />Caw) 46&3400 <br />UNDERGROUND TAN)C 1)LSP0Srn0jj TUCIUNG RECpRf) <br />•••..•..••.••.••.YY••..•.••.Y•YYY.YY•Y.YYYYYYYYYYYYY•Y••Y•YYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYY.•. <br />SECTION I • Public Health Services Tracking Sheet Will accompany each tank affixed with ite site Identification number. ll <br />Tracking Shcet is to be returned to Public Health Scrvu= v.lthtn 30 M of aeeeptaaoe of the tank by the d4posal or erycln <br />facillry. Tho perutlt holder IS «spoosible for ensuring that this form Is completed atld returnetL <br />FAC1LM NAM& w4RT <br />FACi1XNADDRESS:_!� 5T2 <br />TANK tD rr39. 5tt1 / —() Tank Dearriptba tTJ70 gRLLov rl'q SOL/icJE <br />••••••••••••••••••••••••.•••••N••YYYYYYYYYYY•YN•••YYYH••YY•YYY••Y•YYYH/YY.YYYYY.YY•YYYY.YYYYYY•YYYY•.. <br />SECTION 2 • To be ailed cul by "goo" o04traClor <br />Tank Removal Contractor; S eln co <br />Address: '/3/ tc% <br />1-14TcH /Pott p pry; 1290,0ES �-o_ <br />Phone-yP. 9LL LZ <br />Delo Teak RemoYed: ")' I `� —� <br />•••••••••••••••••••.•••.YY•YYYY•YY.YYYYY••YYY•YNYYYYYYYYYp NYYNYNNYYYYYYNYYHHNNY•NYYINYYIYHH, <br />SECTION 3 . to be filled out by 004W&OW 0oco&WWjG&U4S WW;, <br />Tank D"a-laminalion Contractor; . <br />Address QLiD 01r./7%4OES7O 9S3S/ <br />---_.....,. Zip: <br />Phone I: i—��% 1 S 4( q4 S3 <br />Aunhorized representative of contractor cCnWcd by signing below that the by the State <br />requlrtank has been decontanthtinted 11194 approved <br />manner as % DeparUwat of kiaa(,th .oWVjGeL <br />1111 ,. 'r <br />Signature: <br />_Tmes.�lp�v' 1 joys L°o,�.n <br />........................................................................................................... <br />SECTION 4 . To be <br />sl p ed ani by ea authorised reprseoutative of the treatmont, storage, or disposal taclliry <br />' Factil[ N aae taak P P g / o�/ie/ /1%rn, //. <br />Y nate: —_ - , <br />Address Poo S/�b Y -?-FST <br />City: ��y_ o.=„_,_ Ztp; 9530/ <br />Phone ar: (�1236 <br />Date Tank ReGefv / (� — /0 ._ 9• <br />Signature. <br />YYYY•.•Y.. HYYI�YY.YNYHYY <br />EM 23 OCP new a/e/91) tq <br />Tltk: <br />YYYYYYYYMYYYYNYYHYY YYYYNNYYY NYYY YYYYYYY♦YYHYY NYYIYYY�YYYYYY YYY• <br />Page 10 <br />A 0t4rut ef 30 )YYs„u Lay tk*A Tis kq.kw 10 <br />