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FP.v'Pl �� I :' 1 :E- 8'y : ' : ��� P . '- 1 <br /> WDERGROUND TANK DISPOSITION TRACKING RECORD FEB 21 198�J <br /> SK'PiJN _ - The San Jovg.zin Local Health Disrrict's Trar�ing - set vill accompany each hank <br /> _i xed with its site ic.,ntification number. The Tx: ig aneet is to be returned to San <br /> .vain Local Health District within 30 days of acceptu --e of the tank by disposal or <br /> -_._!7 ing facility. The holder of the oermij;_ e d umber M1,,W below is responsible for <br /> p * +r thai- this form ig g2Mleted and_ r*qZ <br /> FACILIT!, .OV�s �icj_2 <br /> - ^_ILITY ADDRE9/5: �ii )s�rl_ ' ��A317� .l l! I''C'f <J�O <br /> :=CNK ID 039-_._1 .'•�" <br /> SECTION - 2 - To be filled out by tank removal contractor(: <br /> flank ftmoval Contractor: <br /> Address: a _ _Z2 <br /> Zip• <br /> Phone#: - (vs <br /> 1'elec'norw: 4 Date Tank Removed: <br /> -��--.-.., .. ... w ���-.-"t+ v..r vj bv.IbLOV IVO '"4GbLI1lwJ1Yl[Id IAPB i:anx••• <br /> Ta k Decontamination" Contractor: h n . �� ✓� r �u J l {r Lr �J — <br /> AddrGss: a nn // L , ®dam <br /> Phone#: 5 <br /> Authorized representative of contractor certifies by signing below that-the tank has been <br /> decontaminated an approved mar,:aet as ma_v be regulated by Department of Health Services'. <br /> SIGNATURE AND TITLE <br /> SECTION 9 - To be filled out and signed by an authorized represnetative,of the treatment, <br /> sto_age; or facility accepting tank. <br /> Facility Namrt� _< <br /> Address: Zip: <br /> Phone#: 5 � � <br /> Data Tank Received: <br /> 1jj,,vjzw 3 ATURE P.NDOrITLE <br /> x#x#******!*x*Y#*xk*##*****!*kxxx#k****!**x!*k*Y#kk#***X**YXxXYX*X*******lYYtYYt!###!*****X <br /> EH 13 019 22/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> p. 0. BOX 2009 <br /> 8'i'OcxTON, CA 95202 <br />