Laserfiche WebLink
5 �7 JCnZCJ2 Zi S.CC.:�., H-7':%T- TH •2 STRS CT <br /> :x**Y#XX**x****YYXYY%XYYYY*XXYYX**YYY**XXY**Y%*Y****X*XY*Y%%**YYYY%YY%YXYX%X####*%#%YX#Y## <br /> ECT <br /> 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> ffixed with its site identification number. The Tracking Sheet is to be returned to San <br /> oaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> ecycling facility. The holder of the permit with number notes low is responsible for <br /> nsu i that this form is gnmoleted and returned, <br /> AGILITY NAME: ?�?� <br /> AGILITY ADDRESS: 0 E � , <br /> ANK ID 039- <br /> YXYY%X#YY%%YYY*YY#X#Y%*XYY%##XY%X#iYYYXYXXX#Y%XYXYY%%#`1 YYY%Y%#YYXX %`E %Y%Y#X#YX%#YY7t#XXY <br /> ECfION - 2 - To be filled out by tank removal contractor: <br /> nk Removal Contractor: PARRTSH. TNC. <br /> ress: 7905 E. Miner Ave, Zip: 95205 <br /> Srnrkcnn_ CA Phone#: <br /> eelephone: ( 209 ) 466-3831 Date Tank Removed: To Be Determined ID- 12-8V <br /> 3ECfICN 3 -To be filled out by contractor "decontaminating tank": <br /> tank Decontamination" Contractor: <br /> +ddress: Zip: <br /> Phone#: <br /> %uthorized 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 /> SIGNATURE AND TITLE <br /> :#%XXYXY#XXXYX%Y#%XX%YX#%X#XXX%YXXXX%XX%XXXYXX#%%X%%%XXX%XXYX##XX#%%X%%X##%X#X%###%#Y##X##% <br /> ;EC:ICN 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name ERICKSON , INC . EPA I .D . NUMBER CAD 009 466 392 <br /> +9dress: 255 PARR BLVD . , RICHMOND , CALIFORNIA Zip: 94801 <br /> Phone#: ( 415 ) 235-13$33 <br /> ete Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> %%Y#X%X#XYX#Y##Y%X##X#%YXXXX##YXYX##%##%XXYYX##Y#####XY%Y%#X#%XYX*#%Xft%#XY#Y#XX#X#XX#XX#X% <br /> W 23 049 12188 <br /> ,AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. �;�iV <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ENTAL HEALTH <br /> ATTN: UNDERGROUND TANK PROGRAM ENVIRONMENTAL <br /> P. O. BOX 2009 <br /> ii STOCKTON, CA 95202 . <br />