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FF011 01 -' lc/o9 1 ? +,i'i F . <br /> �• , � ��t �O�'IN L4C2-YL HF.�AZ�TH.i!]TSTE{2 i�CT'�iy`��I(�� <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xzztzta�nfifibfi�fiR�**gA'A'$�t!ltSttstttti#YfRzzz**xzz*RxtkMNM1MAAfAbAAifi�MMi4 MM1Mf�Yl�*}F*g�xx <br /> Ste711%.V _ - The San Joaq :in Loral Health District's Trarripg set will accompany each tank <br /> faxed with its site ia.lntification number. The Tr., ig aneet is to beEXOtWVOW,ta1 SAnAh1 <br /> t� gain Local Health District within 30 days of accept.....=e of the tank by di le b .CES <br /> -ling Facility. The holder of the rEmit pumber nc�Qd_below is responsible for <br /> !z ;•,I;q_•that this form is Qo=leted and ,;_r*VL _ <br /> TACILIgy 01lE _ '/y0 - 6q LVI <br /> ,-trILITY ADDRESS; <br /> 1AUX ID 1139- <br /> •fxxzzxxzzzzz+exxwxxzx*xxzxxxxxxzxxxz*zzzxxxxzzzxzxzzzxzzzxxzxxzzr�rxxzxzxz*zzt+exxxxzxzzzzzzz <br /> SE7CMON - 2 - To be filled out by tank removal contractor(; <br /> Tank Removal Contractor: <br /> Address: V A _ r y � � �� -a �t -Z: SZ) Zip. <br /> Phone#: _ - <br /> Telelinone: icL)_ e - S 5 3 S Date Tank Removed: <br /> zxxxxtk:txxz**zr�r- , ,a*x*iczzxzz:xxtzxzzxzxx:xxxxxxzzzzzzzxxxxzf*fi��A��finfifififififififififiiYtttilfl�i <br /> _—.•_�..., v ... .,,.. �r__�z+ ..... Lrr •.Vu4LOL.LUL "UGZ:V/Il.eflNl[IdIJ.pC] c;anK••. <br /> lank Decontamination" Contract-- <br /> Address: 2200vm�b � cy�-,�zJ zip. Z <br /> Phone#: ( <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated I an approved Yaayome as may be regulated by Department of Health Services. <br /> 1 <br /> SIGN '1118 AND TITLE <br /> zzxzxzzzzz*zzxxzxxzzxxk*rzxxzxxxxxxxxxx*xxxxxxzxxfxxxx*xxxxzzxzzxxxzxxzzzzzxxxzxxxzzxxzx*xf <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> sto=age, or c.iroos�til =acility accepting tank. <br /> Facility Namc <br /> Address; �t Lcc7 Zip: <br /> Phone#: O� <br /> Date Tank Received: n� <br /> ALAIWKIMU 3IMNIURE AND TITLE <br /> x,tzxazzzzzz,t,exxrexxzzxxxfz*xxxxxxxx�**aaxzzx,rxrxxxx:x,t*x*xxxxxxxxxxxxzxtrxxxxtrrrxxt#xxx*x*xf <br /> EH 13 019 12/88 <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 /> STOCKTDN, CA 95202 <br />