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F,4,N aOAC TJX4 LO=Ar. HMAT�TF LSI S'1 :r CT <br /> UNDFR(P(MD TANK DISPOSITION TRACKING RECM <br /> }*}i}►six*E*R*RR1►ttRRlCtb�ttt7tttttttttttttxxt}ttt#}RRt}wrwwrrrrrrrrrrrrrrfiwrrwwwwrrr##w##*Y <br /> 8 ;%tA4 _ - The San Jozgiin Loral Health District's Trar+ing - set will accompany each tank <br /> :ttxed with its site ic.,ntification number. The Tr, iq Sneet is to be returned to San <br /> _yjin Local Health District within 30 days of accept...-:e of the tank by disposal or <br /> facility. Thr holder of the permit a WL_nUMj2Cr nQto below is responsible for <br /> ;in_that this form 1a completed and.. ,L,.*� _ <br /> ACILITY ADDRESS: !_(`L� .) ru � �ln�c�' . tl-?C1: <br /> •tttY*Y**#*i#xxYt**#t#}}#*tx**}*}**}x****Y}*x**k**tt}*!!Y*****ttlrYYxxxt*!#EFIQYWfr**�k'i►�k%tt*t <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: �t.s-1 J zip <br /> Phone#: �l,.S'. -SS3 <br /> Teiepnone; i ii). L,.� 5 3S [kite Tank Removed: <br /> }k*axtz!**}****r-- -.+*****}*ktkY*Yx*****ttttt*Y*Y****!*ktxxx#YtrQ���h61i8t(ilndiiR8R81(Ritttitit <br /> _�,•"�,,, ,. ... w .....:v vur u] b4u LLOV LVL "4C1:V11{.elW 1111WLin�J l:dnK" . <br /> :`anis Decontamination" Contractor: L1C 'l <br /> �nn rr 1 . : G.Z ,�Z _ Zip: <br /> Addra9s: it YY�612V <br /> Phone N: q11, <br /> - <br /> .S <br /> Authorized representative of contractor certifies by signing below that_ the tank has been <br /> decontaminated 1 an approved Yowait:r as may be regulated by Department of Health Services. <br /> SIL24ATURE AND TITLE <br /> SECTION 9 - To be filled out and sinned by an authorized represnetative of the treatment, <br /> sto_age, or ell facility accepting tank. Y <br /> Facility Name <br /> Address: G`i 7G / <br /> / Rhone M: 5 F F O Zr� <br /> Data Tank Received o? - /� C S-fib 6,1 /000 <br /> c <br /> 'WV <br /> 1•t1UKj LP:D 5 AV-IRE ANDOrITLE <br /> YY******!*!***t***t************Y!Y********kt***Y****t*tt*YtxY}tY!}t**!x}}ttttYY*}t!#x*t!!tt <br /> EH 23 019 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAL$. <br /> SAN JOAQUIN LOCAL HF-ALTH DISTRICT <br /> ATTN: UNDERGR"D TANK PROGRAM <br /> p. 0. DOX 2009 <br /> STOCKTON, CA 95202 <br />