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� N .70AiC TIN LOCAL FMAT•'rl- I]x .9rMI4=W <br /> UNDERGROUND TANK DISPOSITION TRMXING RE00RD <br /> lRt�!►:�x��***x***tR>tSi33!##2tt#ltttttttttt###!!!t*RR#fi*w*AA**rMAr**#r#•*4**HYMN**#*#**!!## <br /> The San Josgzin Local Health Disrrictfs Trar+inq " set vill accompany each tank <br /> :fixed with its site ld.,ntification number. The Tr: ig Sneet is to be returned to San <br /> ,-&quin Local Health District within 30 days of accept.. .-Ze of the tank by disposal or <br /> ;n-linq facility. The holder of, the permit th number noted below is responsible for <br /> e r1(Lthat thin form ig g2Wleted and <br /> FACILI^_'Y ANWRI r / C92�F7� yJ l <br /> I>CILITY ADDRESS: P) <br /> =4K 1D 139 <br /> '.YlY#fi#**#*i*tYYR*fi*t*!fi!#fifififi**#!fi*fiR#fifiYRRfifilfiR#RlRfifi#t#Rfifi*RYYfitt!!#fi**tlRttY#!***!!#ttt <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: A,) <br /> Address: <br /> ip- <br /> Phone#: -SS3,S <br /> Telephone: ( �I/r., )_. S:2 - �s Z5--s �?— FDate Tank Removed: <br /> !fi*fix�fitfiRtfi*�t''x--"`•--.e*#***!!tR!!!#ttfifi!llRtR*!!!#*!RR!!t!!*tt*!*��EEhRllililllil1111Tf$SildSttttitEi <br /> --�.�•• _ ._ w ..a�4v vu� ✓r 4.Vu4ae44uL "4�-b(III W`101I106J.O9 udnK". <br /> Panic Decontamination" Contractor! - <br /> Address: UDO al..! <br /> Phone#: �[ <br /> Authorized representative of contractor certifies by slgning below that the tank has been <br /> decontaminated I an a roved irY Ras may be regulated by Department of Health Services'. <br /> i �y J <br /> SIGNATURE AND TITLE <br /> t!*#**!lRRt*tt!#****#** *ltttfi*fi**tttRRR#Rtt**R*tRt!*t!t*RRlRttlYt*tttlRRRtR*Ytfi#R***fitlt <br /> SECTION 9 - To be filed out and signed by an authorized represnetative of the treatment, <br /> storage, or c.iexsal facility accepting tank. <br /> Facility Name <br /> Address: _ Z4 J e7 Z1 <br /> Phone#: If-IE <br /> Date Tank Received: je <br /> AVl•HUNl'LN� 3i(3IATlA AND TITLE <br /> fiRfiRfifi**!*tlfifiYttfi#****R*fi#lRfifiY:YYfififi***fififififitlfi*fififi**fiR*#tY!!!fi!#*fi#*tlRYYtfiYYYtR*RRfifi*fifi <br /> EH 23 019 12188 <br /> HAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .�) p <br /> ATTN-P. UNDER <br /> 2X GROUND TANK PROGRAM ��J( U _ ,1 <br /> FEB 2 2 1989 STGCKTON. CA 95202 " G� <br /> ISI <br /> EN%,,,0�MENTAL HEALTH <br /> PERMIT i SERVICES <br /> . i <br />