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•_ r c121.N �?Olr VIN LC7C23.L fiF--ALT DI uC'2'F2S C'I' <br /> UNDERGROUND TANK DISPOSITION TRAMING REUORD <br /> *RRRR►:�x/i1�xRRRRRR*R*i1:4�!!Y2**YtRYYtttt}YYY#*ftY*RRRkk*****I��Yti*t***iit*411A11Y#***!*t**!*Yk <br /> SF','PikM - The San Joaliin Local Health Dis%xictlz; Tr=-"ing set will accompany each tank <br /> :fixed with Its sit* io ,ntification number. The Tr q 3i,aet is to be returned to San <br /> e-wgain Local Health District within 30 days of acceyL -e of the tank by disposal or <br /> �-?ing facility. jbg holder of the oergU • Ul-n ember "`_g below is responsible for <br /> cnk,;"jjc .that this form•a ggmnleted and, <br /> FACILITY ++wi � <br /> 6CILI7Y ADDRh38; Uj <br /> "l-dM .D 139-� MAS 2 1989 <br /> SECTION - 2 - To be filled out by tank removal contractor: ENVIRONMENTAL HEALTH. <br /> PERMIT/SERVICES <br /> Tank Removal Contractor. 1�.,_ � <br /> Address: �Aq,S tZ> Zip• <br /> PhoneM <br /> Telephone: Date Tank Removed: <br /> #xx%Kitx#*!*RtxY•- !xxRt**!tR*YYYttt!ltRRRtttttYt#!*R**RYYlYlt*��nAffR8litfiHlil$$IiilitAllfit/iiEt <br /> --..,-.,... .. ... w ....vu .+✓. ✓I �.vu..ie�w� "4G1:VII WINI/1d 110CJ tianK".( <br /> Tack Decontamination" ConrractOt: Lherrn — <br /> Addcasa: 2200 /-L-e,1Lo l k- ,7 ('A —zip. �JTJ <br /> Phone I: <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated : an approved row4wi au uwy be regulated by Department of Health Services. <br /> 1 <br /> SIIAVATURE AND TITLE <br /> RkRkRt!!R!*R#kkk#*!!**t**t*t***R*t**lRkt*!R*tlRtk*k*kkkkxltRR**ttYYYYY***Rtltt*tY#*!!t*tttt <br /> SECTION 4 - To be filled out and sb�aed by an authorized represnetative of the treatment, <br /> rto,age, or facility accepting tank. <br /> Facility Nan gMFRTCAN _METAL _RECYCLING , INC . <br /> Address: 2202 S . MILLIEEN _AVE . , ONTARIO , CA Zip: 91761 <br /> Phone#: ( 714 ) 988-8000 <br /> Date Tank Recelvedi FFRRTTARY 21 . I98 - Twn 5000 CAT.T•ON TANKS_ <br /> 2EFICE MANAGER <br /> Av111tA(1ZW 5LMATURE AND TITLE <br /> k** #***#!! Yt*!!***Rt!!RR*YYYYRtx#tRRltRtRlYYYY********!*tlRR#**!RR*tRRYttYRRR!#!!Rltttt <br /> EH 13 049 1 /88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMOROWD TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOW", CA 95202 <br /> Ti^�TFiL F' . I I <br />