Laserfiche WebLink
SAN ,70,7,'CuI Lv T..00 ZLT. HEAI^.'TI-i Dx SS7S-11 CT <br /> UNDERGROUND TANK DISPOSITION '!RACKING RZ ORD <br /> r*#XWxwfix##xXxk**xX***#*x%x*wWx****x*W#**xWWkfi*wW*W*###wx**fi#WW*******Wx*x***ww*xW*WxxW***x <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 /> 7oayuin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the nermlt with nunh�_ ron ted below i,y-sponsible for <br /> -nsuging that thi9 form is completed and returned. <br /> ^ACILITY NAME: ST: =g.:P F1 F, T-A l <br /> FACILITY ADDRESS: [SC)Q ►Jbi✓TH CAU& STQ_ S-T-0Z K`fO1J 9 Sr1Cl <br /> rANK ID #39- - <br /> t*#X********x**71'*X*w****xx*********%****#*;t*****xwW%xw**wW*%*#x'Wx7�x**#*%WX**x**kWwxx*xx**W* <br /> 3ELTION - 2 - To be filled outby tank removal contractor: <br /> sC <br /> 1`ank Removal Contractor: �"n `e <br /> address: X4-31 w, H- -t4 ( Zips 9535- 1 <br /> MoCEZ` -6 t/' 14 Phone#: 4-Ci <br /> , <br /> Telephone: (�_;01_) �� ' ��� _ Date Tank Removed: <br /> rWwzzwwxxxzxwxzw**#xzxxW***zxzx*#*Wx**w#WwWWXxxW*xWwwxw**zxxxx*x*wx*WWW*xx***WWx*****#Wxx** <br /> 9ECPION 3 -To be filled out by contractor "decontaminating tank,": <br /> rank Decontamination" Contractor: SEYyl(y <br /> address: 4I u) td( (��_ Zip: S3 <br /> Ync) �—`�� aA Phone#: <br /> authorized representative of contractor certifies by signing below tMt the tank has been <br /> Jecontaeinated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> rx*Xwxxx**ww#wxwxxxxw*wwxxxfi****wwx***x*zzxxWxx**x*Wxzx%Wxfix*#xWx%**xwx#***#xwxxx***wxx*x** <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name i-C— /LY� MR C Z <br /> address: (00c> —Zip- <br /> Ie I <br /> �J3 <br /> C H MOAJ 1i--• PhoneN: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Eli 23 049 12/88 <br /> `W LING INSTRUCTIONS: BOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAA'K PROMAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />