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FX1N .70AQLTIN Lcx- IULAr'T'H I?ISTL;;Z1 .' <br /> LHDB --XMD TANK DISPOSITION TRACKING ...,OORD <br /> tf*kt►i Rx NoNoga$*Mta*lst**Sea attt****tttt*t*tt***RRAAMAAAAAAAAAAAAAAAAA*AAAAAAAAAAftA■tYR <br /> SK:J'1vN _ - The San Jo&,IAn Local Health Dla�xictl,i TY—I- ing set will accompany each tank <br /> :tlxed with Its site id ,ntification number. The Tr q aAmatt is to be returned to San <br /> (1,wy1in Local Health District within 30 days of accept -A of the tank by disposal or <br /> •: !c-ling facility. The holder of the prmitntmber nc*Ad below is zeanotuible for <br /> eua �i_na that this form 1R completed and -*IL ) <br /> FACILITY uUs1 �l� i/ [9Qll� <br /> tbCILITY ADDRESS; <br /> TAtdC iD 139- <br /> ctttttettitlRRt*Rttt**tRttR**fktkRRRRR***RRRkttRRRRRtkR*t*f**tttRtRR R��RR�Re�RR tRt <br /> SECTION - 2 - To be filled out by ta�n'k/removal contractor; r �tjj <br /> Tank Removal Contract or:_-1d.d1:�..o J �A ,� 1C> D�o ;�'.j7/;L t.{c,LTI-I <br /> AR a.GE++ivE6 <br /> Address TacoC� Q'sl ti I Zip <br /> Phone#: c�- <br /> Telephone: ( �). l(,i!2 " 5 �5 3 S Date Tank Removed: <br /> tRR1KtR**Rt*R Ywt : ''t*R**R**RR*lRYRYRRRRRRRRtYYRRYRRf*R*RRhRYYt�tQ���h���xx�ARAdttitti)fllitlt <br /> --.�•....• .. •.. w .•..w v..r u) 4Vu4a�V4VL "401.V�14YRIl/1dL�nC� .1%;4nx"U.(r' <br /> Tank Decontamination" Contractor: — <br /> Addtaaa: 7200 ic1'1z, � ('A �L'�:->o- Zi <br /> Phone#: L. <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> d000ntaminsted . an appy manrwr as may be roqulated by Department of Health Services. <br /> 1�) �n� L"-L- <br /> IGiNATLRE AND TITLE <br /> ttRYR*ttfttttR**Rk*RR*R*RR*tf Rttkk**ttRRR*aRRRt*kttttkktkt*tRttttttttRRRk*ttttttetRRtttRttt <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> sto,age, or uit,�ooil facility accepting tank. <br /> Facility Name .AMERICAN METAL RECYCLING . INC . <br /> Address: 220? S . MILLIKE AVE — ONTARIO . CA 2i 91761 <br /> .V 0: F714 )988-8000 <br /> Date Tank Received; FERRuARY 21 198 - TW0 5000 CATJON TANKS - <br /> 1QUICE UNAGER <br /> *t* K1ALr1'HUtI•Lt:U SICNATIR& AND TITLE <br /> 8 <br /> tEH 23 019 1 <br /> MAILINO INSTRUCTIONSt FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAM. <br /> SAN J04UIN LO('.AL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br /> TOTAL P . I1 <br />