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', .+a-w.,♦ v vs LV 1 4v 4-.v� -•• til!�.E�iL�'1't. I]I u�TR I CZ' <br /> r <br /> IAVMRGtOM TANK DISPOSITION TRACKING RIDOORD <br /> !*!!!!lRfififit'tfittAttttffftlfttYltttlfftfftt*R**kR**RRRR*AAAAAAAAAAAAAAAAAANAAAAAA*AA***R*R** <br /> SDCTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site Identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. ,._ <br /> tM <br /> is form <br /> YACILITY NAM-Lo-of, Ila _���1(�1 fta /VAP C^,1 <br /> FACILITY ADDRESS: , <br /> LTH <br /> TANK ID Y39- <br /> 4*ttR**k******kk!*****!kltk**RkhRkR*tR*tkk*k*t***kltkRRkt*RRtlttflkktRR***RR*Rttk***k*k***R <br /> SP.MON - 2 - To be- filled out by tank removal contractor; <br /> Tank Removal Contractor:- &) <br /> Address; 1U_(1 �(� 2Q�c �ly�,k��_ X �� a�� �J Zip. <br /> Phoney: ,-�,,5" -Ss3S" <br /> Telephone: ( ) Date Tank Removed: <br /> *Rtt*ktRtk*****ktkkt**R*R*t**Rkt*R*k*RRkt**Rtttttt**k***tR**4*t*6fififiAfifififififififififififififitttftttf <br /> --�•��•• - .� w .r.aw ..... ✓� ..✓n..ao�w� -uGLvu WIYt(bliPg {raf1K". <br /> Tank Decontamination"-Contractor: �V i <br /> Address: zip: 1---.5 <br /> Phone Y: ( - S <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved Y&iw*Y as may be regulated by Department of Health Services'. <br /> SIGNATURE AND TITLE <br /> � *4**kk*tRRk*4k**kRk****Rtk*t**kk*k**RRR*Rkkk****k*tR*RttkRR*R**4tlt*tkk****k4tttkt*k******* <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: <br /> 21p: <br /> Phone Y: <br /> Date Tank Received; <br /> AV111U11ZW SIONA71JRE AND TITLE <br /> R4**RkR**kt*4*RRtR*Rk*R*R*R*Rttt*R******RRR***t***R*****R*****RRRRRRk*tlRtttttttRR**R**R*tt <br /> EN 23 019 12180 <br /> HAILING INSML=ICM: FOLD IN HALF AND STAPLE. AFFIX PROPPOSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AM: UNDERMOWD TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOUCTON, Chi 95202 <br />