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Rt,Tt:t:rtrR:::tr;r:RR;;: DIa00ITION TRACKIlrq RECWD <br /> J"EL'ff�N 1 _ The San uP, <br /> Local <br /> rrrrrtfrerttRrRratrrrRRtrtttR. <br /> affixed with its site identification nth District' _ rttRRrlrrttttrrRR;trtRRRyttRs <br /> Joaquin Local Health Diatrict v1 weber. TMsTrackli� shoot Will a�nY <br /> recycling facility., thin 30 days of accaptanoenofhoot is to be returnedtotan <br /> the tank by disposal or san <br /> FACILITY H&W: <br /> FACILITY ADUiESS• t <br /> TANK ID 139- � �1�C.lZ�t� c 5o2�J <br /> •ttttttrttRtRttltRlRRlrrr afffRRrRRRrrt;RRRRRrrRRRtt;Rrttrt;fr/fit <br /> SECTICrI - 2 - To be tilled out by !molt removml �a,lttaCtor: ~ rrttr:r*trr;rrrRt. <br /> Tank Removal contractor, S E M C O <br /> Address: <br /> H ch Road <br /> Telephone: 2� 09 r_524-9653_ i::i�n4_ <br /> ttttttttttttttttttttttttRlfrtrtttrttrtDate TW*tttRoved. R;ttrt <br /> SECTION 3 -To be filled***t b Date Tank Removed. <br /> Tank y contractor R� �t�g ta,�GR• Ar;Rats;tart;rtatrarrrRta <br /> Decontaminationo .Contractors • S E M C 0 <br /> Address; 431 West 'Hatdh Road _ <br /> M C Ii ornia <br /> ZS 95351 <br /> Authorized representative ofd' zE965 <br /> decontaminated in an aper contractor cartlfiea by signing beloW that the tat* has been <br /> may be regulated by Department of Health 8ervlcea. <br /> f r'M TITLE RRtRrRt; <br /> SECTION 9'`tRttt"�t'tt*t*tr:R:trrrrrrrRrrttr;rrrr- To be filled out and sic <br /> storage, or dis by an authorized re 1►rRRRRttRRfrtrYRrRRRtRt <br /> poral facility aoosptLW tjny yam. preanetative of the trey <br /> Facility Name_ treatment, <br /> Address: <br /> Dute Tank Received, 2 _moo <br /> ttttttttttrtrrrrt:tttRRRtrtrRRt;rRrrrrRtrR81 AND TITLE <br /> EH 21049 <br /> TAI12/19 rttrttRRtRr;trRt;RrrrrRsfRrRRrrrtterrrrrrtRtr <br /> LING INS4RUCTIONS. FOLD IN HALF AND STAPLE. 4MX PfLOPisit per. <br /> ANHEA <br /> �OAMN LOCAL LTH DISIRICT <br /> P. 0. WX TAW PitOQiAM <br /> gTooTogo ca. 95202 <br /> 1 , <br />