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:3AL4 C I <br /> UNDER(;­-"4[ F&t4 C : .:: !,xJ 15W_Y IN!; Ii (L, <br /> **x**AAAAAAAAxA*x*x**w**w*xwxR**ARRA****XxXRRRXnR *x******AxX*w*w**xAR*XAR***xfiwxx#Aw*##tfix* <br /> SECTION 1 - The San Joaquin Local Health District 's Trackinq Sheet will accompany each tank <br /> affixed with !ts•slte 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 holder Q . the cYni,:-4_��rh nwit, .i 1, tr, <br /> ansuring that this for - --�-2�-low i:= rgsoo atbl for <br /> ls�on > >te a re ter, <br /> FACILITY NAME; r1017-Cal Bevo, <br /> FACILITY ADDRESS: 11300 t': , ,:.c . <br /> _ 7')zus <br /> TANK ID N39- � �� _ ', �OD �(!u1[e/ <br /> nR A "AIR **AAXRxA*RAR*RfiXR**x*#*wfifi*fifiwAw##fifi** <br /> SECTION - 2 - To be filled out by tank; rem _ contractor <br /> 'Dank Removal Contractor :_ r „ <br /> Address <br /> ' 45f�B <br /> Telephone: Datc Tank Removed : 916-652-5535 <br /> SECTION 3 -To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination" Contractor : <br /> Address : Box l „ <br /> Zip: 95650 <br /> _PhoneN : <br /> Authorized represen ive of contractor certifies by signing below tltiit the tank has been <br /> deconta ated i ppro a nfc as may be re,u�llatteed by Department of Health Services. <br /> XXxxxx 9!QJA'P'�.E TITLE <br /> xx*w*xwRR x'*t*xw*xRR1*X Rx Rxx xx*FRF*xRx**wxxxRx **x*Rxxw xx Rx*R RRx Rxxx####fiwx##fi#xww <br /> 3ECTION 4 - rl d out and signed by 6r, aurnorizeu represnetative of the treatment, <br /> storage, or disposal f ility accepting tors. . <br /> Facility Name blow <br /> Address - <br /> -�tJ-- <br /> Date Tank Received: <br /> AUi'HCIR I ZED = ) m_r., Aj ` :. ,;j.,..E <br /> AX*R*AAA#A A AA AA A**w*AA AA AA*x*AIRA ***X*A *ARRA AR nAXXXA IRA n AX A AAR**RA *RAR <br /> F,II 23 049 11/88 <br /> MAILING INSTRUCTIONS : FOLD IN HALF AND S77u LL . AI'FIX PRUNER POSTAGE, <br /> SAN JOAQUIN UXHEALTH DISTRICT <br /> ATTN: UNDMCT.CrJND TANK PRMCAM <br /> P , 0. BOX 20J5 <br /> S'[CXY.7CN, CA ,< <br />