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r• - ti"J!.'1.A_tl , 4/� \�.F.41 h../®Sr.tTAJ li.a�..ca�..1�� y���'�. ��^4t�� . <br /> UNMORC)UND TANK DISPOSITION WcKING Rk1Ck"kiD <br /> k****kfiNAh'***#*#**h*N***AAAAAAA*A***RA*Nhk*A*A*A'AA****fiA*A***ARRhkAA#*kR•h#***#*Rk*A#R'RRARA*' <br /> SECTION 1 - 'The San Joa(juln Local HecaltY) Dist:rict's Tzackinq Sheet will arconapany each tank <br /> affixed with its site identification )au:ataer. The 'tracking Sheet is to ire returned to San <br /> Joaquin Local Health District within 30 Jaya of acceptance of the tank by dispo:aal or <br /> recycling facility. :CI4..1al-f1ta 9f 5;.b.:...it2.1Wr1 L WVfjl <br /> FACILITY NAME: CI 1 ta, <br /> �� g /_• _ <br /> FACILITY ADDRF:ss• 2//5 �1�. +:(,!/ �Yi/ H���T_' <br /> TANK ID 139- �Z4Z C� I <br /> *hAR**RA*******k*A**R#fiR*RRAArtA*Ak**A**k**kfiRNAA*#*#*kAfi***AAtr#*N****RR*fikA*AAhk*AA*N'Rh*A** <br /> SWTION - 2 - To be tilled out by tank removal contr tor: <br /> Tank Removal Contzactor: Y —,,aU 4 (e u< �Q - <br /> Addfess: Q, IJDX 7`jj <br /> 9 � �' <br /> Te 1pi3tirnie: ( 9/S�) 4 �� __"Cate Tank Remved t___ <br /> **k1iNNiFkNkAAN******k#AkNR*AAAk#k*fi****N#*##N#**A*A**AA**A**hAhh*#**kAk***rt*9:hkANA*A****NfihR <br /> 8bCi'ION 3 -To be filled out by contractor "decontaminating ak": <br /> Tush Decontamination" Contzactor: `Trra,v� c GtCj p �ae <br /> Address: _f�Q, BX 4)9 y <br /> C , _ zip: �5�2 3 <br /> . aD <br /> Authorized representative of contrdctar certifies Gy signing below that the tank has teon <br /> deconta�ia tedapproved aanner as nay I regulated by Departwent Of Health ervices. <br /> « �s <br /> 'a`IC�IA'IVRF ANU TITLE '"""-- i <br /> *hhRkRk*A**�#**A**N*k*k#A**Akhkkk*k*fiAk*k*:hR*AA***#*5pkk***k****AR*Ahkk*h*RkAhkRA*'h AxhA*#AAt <br /> SE VION 4 - To be filled out and signed by an au0jori7ed represnetative Of the tzeatinent, <br /> st:oraga, or disposal facil ty accepting tar , <br /> Facility Names` P N r 0 <br /> Address: 51 .. 95823 <br /> Date Tank Received: <br /> AU9'HORIZED SSIC3J,AIfJ AIlD TITLE <br /> *#AR#**kfiAk'*kh**A#*#A*k*A#AA*A#RA*NNfikRk*R*kR#k*R***RAk*R!*kh*AA'**kfifih**hN****N#A**Ahkk'kA** <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD .IN HALF AND STAPLE, AFFIX PROpM POS7'AG°E, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDFMGROUND TAW PROGRAM <br /> P. 0, BOX 2005 <br /> STOCKTON, CA 95202 <br />