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SAN ,70AQT 1'l xq X.C�"A - �..'TH O T SSR x r <br /> UNDMICROUND TAMC DISPOSITICU TRAMING REWFO ` <br /> SCTION 1 Ue San Joaquin Uncal Health Diatrict's TraOcing Sheet will any each ,tank <br /> affixed with its site identification number. The Tracking Shftt Is to be returned to San <br /> Joao n Local Health District within 30 days of aweptanc a of thc: tank by dispo l or <br /> recycling facility. <br /> 90=1w4bat &W5- low ig c=11t ..a0d XeIZUW. <br /> pAILI'F`Y 1AF'ii.: AI , f � <br /> nai'ITY <br /> TAW xD 039-- <br /> SWnON - 2 - To be f i l led out by tank removal contractor: <br /> Tanis Ramal Contractor: -- <br /> Address: ,q CC P-L1' 1 rA , CAZip: Gl � <br /> F OM#zfi'Q����r <br /> Telephone: tom? .,67� ,: ZOO bate Tank Removed <br /> **#*�**w##kr*Y*Yir'#!r**lrfr*t#*#sloe#wit*�ririrt**#�;**�**#*1r*vr**kakd�lkk�*xfia7kKrY****rikatx�t##fir*�c#�k+k�ktkl�Yle* <br /> OWrION 3 --To be filled out by contractor "decontte.winating irk": <br /> Zu* Decontamination" Contractor. i 5Q <br /> r <br /> Address: 'Z?-j2 CJJJ� A 4j. <br /> Authorized representative of contractor certifies by sicp.ing below that the tank has been <br /> decontaminated in an approved naru)er as way be regulated by Department of Health Services. <br /> SIGMTURE AND TITLE <br /> it#art##�t�t**www *k�*k�r1t�**t1t�CYt*Yrrr*wfcY�kirklk#*XR**�R#tx##�xx+rttk*k��x�t**�rx*�k�7takY*#�**�*****�*7k�k1r* <br /> SWrICV 4 To be f:11ed out <br /> OK- dksr�Gal <br /> I <br /> Facility Nam fl S <br /> Address: UP: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHMIZED StONJOURE AND TITLE <br /> iktt*"�'***�t*R*'kitlk#rir**tY#4Y#!1'1fy1'�r lirliifA**t�lrxklaY#"�R*1Ci[*****W'*itlr*11'J�*#�'#rk�Y�retR117kif7k#lrltlk*1t*�ilrlk*#i'lc'k**1K ft�FM <br /> EH 23 049 12/88 <br /> KMING INSTRUCTIONS: FMD Its HALF AND STAPLE. AWIX PROPER POSTAGE. <br /> SAN JQR{IUIN LX.AL HEALTH DISTRICT <br /> ATTN: UNDERMOUND WANK PR03RAM <br /> P. D. BOX 2M <br /> S'i'=TC3N, cA 95202 <br />