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1�'. JP FF.'i7P1 0 L i QIP -I•IE- <br /> _Di I1I_rii,11LI I j h .�'='. �� <br /> UNDERcRUZD TANK DISPOSITION TMCXING RtjC)MD <br /> SFX.VIQ4 1 The Dan Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification nurrLt)-er. . " Phe Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 Clays of acceptance of the tank by disposal or <br /> recycling facility. The holdar o .�h� �EYmi wytj�.gy ?��gj�elow <br /> P.MajAg that this fprigt_Co luted alb, > eturpo, <br /> FACILITY NAMIv': quip Lumber- <br /> £AGILITY ADDRESS: • �jy "t-,X <br /> TANK ID 139. �', , ;!-�_- )- <br /> Xh'fi'h**R'**fiwRR'R*h'*k#IFR'R1Yf[X*'R'*kh*****'hkW*fiYfXkR**R'*w*Rwwwk'*AkWkxwRRh*#AR****hfi#*w#h###*wWWW*X* <br /> &F;MON - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Weldon. <br /> Address: .C. Box 69 Hicl�nart. <br /> ._ __Phone$: 374-177_Z , <br /> Telephone; ( Q2 )_£ 4-3722.Date Tank Removed," <br /> SFX,TION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank DegontaminationO, Contractor: W�„j <br /> Address s F.0 M 2 <br /> Phone#: _-1 ' <br /> Authorized tepresentativa of contractor certifies by signing tr_low thf-it the tank has Leen <br /> decontaminated in an approved manner as may Iia regulated by Depbrt:ment of Health services. <br /> 91WA771iRE AND TI'T'LE <br /> k*www..rhwwR*#h*fiR*wzww**wxWxR#Wkk#***k*W#w*x##w***:+*##z**k#wz*fiwkkW-kkwz•x*k*W*zzw*x*k**wxhx,rk <br /> SMTIoN 9 - Tp_1'A f1Il.ed out and signed by an authorized represnetati.ve of the treatment, <br /> storage, or disposal at T ce�EZnry-t <br /> Facility Name � <br /> Addresst 47G�Stree Pk>dq��q �� 95351 _ ,Zip: °S��J <br /> Date Tank Received; <br /> AWHORIZED SIGNATUM ANC? TITLE <br /> wfi#*Rfi##WWW*k#WWR*******#fi*k***w***#*WWWwkkxkxx#*#*WfiR*wwxkww*kkW*Ww'WkWwkkW****wtWkwfiwWkWw* <br /> Ell 23 049 12les <br /> 1�AILING INSTRUCTIONS: MOLD IN HALF A14D STAPLr, Ar pIX PROI>FR POS7'AGh~. <br /> SAN JOAQUIN U)CAL• MALAN DIS•IRIC'I' <br /> A71N. UNC»: ICROUND TANK Fnocm M <br /> P, 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />