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I':+=+1_1 11. ::1 FF'014 OL i ill 1.ia,q-pail 11aE—LL I .1 • <br /> LVDMMOUND TANK DISPOSITION ;RA(XIN(3 R )i )RD <br /> w#xWkkkkR***W*Y*k*xW*kR**k*k*k*k**kW**Wfi**kk**�rxWkW***!1**kk**xxxKwW**W***k*W*********r*Rtxr <br /> SFX."1'ION 1 -- The San Joaquin Local Health District's Trecking Sheet, will accompany each tank <br /> affixed with its site identification nunber. , ~The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tdrtk, by disposalos <br /> recycling facility. X21 oldar 8 .,118 } ltlwdth.q '�114 ' i?e- =2. i� rem _ o <br /> PllFur nota his fpm ; o �� ea al�w _ wau �ble _ <br /> FACILITY NW, - <br /> FACILITY ADDRE$S: tS- iVgi},�,ySr, Cktcn• ( $ <br /> TANK ID 139- ?_. <br /> SWTION - 2 - To be filled out by tank wemoval contractor: <br /> Tank Removal Contractor: 4;eldon. _ide�ii Ib, <br /> Address: ,L.Q., TBox 69 Hickmjc>. Zip: �J_3 <br /> Telephone: t Z2 _ � S74- i%7 Date Tank Removed,,, <br /> SBXTION 3 -To be filled out by contractor 'decontaminating tank": <br /> Tank. DeContaminationo' ContraCtor. : W h ldsxa agl�� <br /> Address: F,0 p,04, 62 <br /> Authorized representative of contractor certifies by signing below that: the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of health Services. <br /> (MV*W��W•k~ TITLE <br /> **fiW***kk*rt*****k*R***kkR*xtx***xkx*x <br /> SBCTION 9 - XQ-1x filled out and signed by. an authorized represnetative of the treatment, <br /> storage, ar�dis sal fac�Tl7t� ceti"ncytar <br /> raci l I ty Name, ,,1 <br /> Address! �4J]�5 gi,�Street hk,dt$to• 95351 <br /> Date Tank Received: <br /> ATMORIZED SIMMVE AND T1TLE T "� <br /> R11 23 049 12/88 <br /> 14AILINO INMU(_PIONS: 17OLD IN HALF AND STMPLT. AMIX PROPER POSIAGr., <br /> SAN JOAQUIN LOCAL HALT!{ DIMIZICP <br /> A717q: UNDL12tn20UND TANK PROLT2AM <br /> P, O. BOX 20109 <br /> STOCRTUN, CA 95202 <br />