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sA ti/oAaL ash w xADc2a, YI <br /> *'��af•fliR*���w����*R�*i��i Ri.RA�n��I���#w''r'�R*# .�7��"���*6l �Ai.�it'ti�7w/�1 ��i �A}��^*�'�*.�'��*�UI*��'� <br /> ZWTION 1 - The San Joaquin Local Health District's Tlrac*ing Shoet will accompany each tw* <br /> affixed with its site identification nuaar. The Tracking Sheet is to be returned to Sar: <br /> Join rel fi lth District within 30 days of ameptrance of the tank by dizpozal or <br /> recycling facility. <br /> FAMLLTY NAME:: nl -Tr, ,u 7+G f Cf M i,s u rrl <br /> mm AMMS: r L/)(,-,j F-i Ave i< 69 Lr F q'U 2 <br /> TAB{ Ib <br /> *ittxilttt�t�r�kttt*tt:tilic#rtk*>till#�tx#t>i�r*t#ilt*tltkt*t>*:elrtt*#t##t#xl4�ct�r*�c11t:r#istx*trxt�#,xlrtr,k##>rrttttlr�Clke*##its <br /> SEMON -- 2 To be :Filled out by tank zemoval contractor, <br /> Tank Rea val Contractor: <br /> Address: C /-A r `Ie_:!t) f t rA , CA zip: P a oof <br /> Phone#sQQ� <br /> Telephone: (.,`' t�" ? �2A?,-ZD I) Date Tank Removed: <br /> SACTICH 3 --To be €1l1W out by contractor "decontaminating tails": <br /> Tank Decontamination" Contractor: <br /> Address: '2_2.Q rjjjn(A- 2,9:5/ - -- Zip: <br /> Lai r 8 <br /> Authorized representative of contractor certifies by slgning glow that the tank has been <br /> decontaminated in an approved maruaer as may be regulated by Department of Health Services. <br /> SIGMTDRE AND TITLE <br /> !f##Rk#�Cll[*hitt**�tfCkt*#71*Mt#�c*tklC�rt*1rk'k*t*alKfrlkX 11 y'##*#X#'ktt*#fit*t#�ktkk#X11*1t#*7t*�1t*�riYr#*1r*#tick#***�k*'Rtl[*'* <br /> SWPIGN 4 - To be filled out <br /> i <br /> F`acillty Name14 <br /> Address: Zip. <br /> Phone#: <br /> Date Tank R ived: <br /> AUT MIZE'D SIGNATME ?t1VD TITLE <br /> *##�*fiklk7rt�l*#Rt#�rtklk>tilttk�1r11#�tirllrktrrl�#1ktMAtt'k�i#tt7t#s#!r*�Y*#�rrk�rytMc�r*xx#�k*tt�rx�#>kis*Ar�rfl*sxlkirlr�llr#**###*fir#1r <br /> EH 23 049 12/88 <br /> WI.ING INSTRUCTIONS: FOLD IN HALF ,AND STAPLE. A TTX PROPER POSTACE. <br /> SAM JOAQUIN LSC" L H MTH DISTRICT <br /> ATTN: UNDE GROUND TANK PROM M <br /> Sr=IW, ch 95202 <br />