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.. . .^'�a�1.f V �./CSQv�� 1.a��.+��� C"Z�'-L r1'Z •�J 1 J'Tr'� �.-^4 + ;.�. <br /> *%*xx*xxx YYtllxSl:ilf%xi.'YYirY'kxYJGX;SYt.Y*fYxftxYiYxitixi�tRlikFR,tSx xii Sifrt*ltFxYxxXxYXYZYit*YYSFi Xi ' <br /> =ION 1 The Sari Jxuuin Local Health District's Tracking Sheet Will actotaE,attiy eaefi tanit <br /> Fixed with its site identifiaacion nurber, The Tracking Sheet is to be .rettitt:ed to San <br /> aquin Local 'rnalth District; within 30 days of acceptance of the tank by disposal or <br /> cycling facility. The holder of the 22rM ,t With number noted below Is resocnsible for <br /> aurina that ch7L� fern i� cnrmpl4tad a�rEturned <br /> '1LTT1 NA1e: <br /> ClL17Y ADDRESS: � /4 <br /> NK ZD 139- <br /> kxriaxzkz:c:R%xxxxxxi#,rx:xxxsxxii:zxiticzxxxF sx i��Fzxi:i x z#Xzz*xxxz:xzxr <br /> CTION - 2 - To be filled out by tank removal contracto <br /> nk 2emoval Contractor: P?CISH, iNc. <br /> dress: „<8 c. miner "Ve. 95205 <br /> Srco!kton CA ��^ Phone$: <br /> lephane; 1 2G9 ) 465-3837 Date Tank Removed: To Be Determined t�-12-" <br /> Rxx*4swxx**k*****.Xkvw************Y%%Gxixxwwwxxzz2xwxwxxww*v*wwxxzwxvx*v*****Xxxx*lz**Xx*e <br /> =ION 3 -To be tilled out by contractor "decontaminating tank": <br /> :!k lk_ontamination" Contractor: <br /> dress: <br /> Zip: <br /> Phanei: <br /> rh^xi=..d of C01'rr,ctor certifies by signing below that the tank has bc�aa <br /> in un ,'��Y;X*Wed lamer as may be regulated Dy 0?P3rtmeAt of Health Servjc's. <br /> SIGNATURE AND TITLE <br /> rxxx.xxizx•i y YY'lY)9Y1'37't;S}q#X'$Yk:'f8rtJfYi*T.PII'x2*xXSxXYi�xxx7BYzxxx7xxxxxzx*xx#x7t7txrx�ixsk![xxx^. <br /> 4 - Ta c,e f:i'_led out and signed by an authorized represnetative of the treatment, <br /> ara,a, cs Ci:,7sai '.acil' ty a_•cepting tank. <br /> .111ty :.oma SRICRSON, ffiC. EPA I D NUMBER CAD 009 466 392 <br /> -- <br /> fress: — 255 PARR ELVD.t RIcIMOND, CALIFORNIA y� <br /> Zip. 94801 • _ <br /> Phoneo: (415) 235-1393 <br /> :a Tank _Receives; <br /> AUfHCRIZED SLGR.IATuR: AND TILE <br /> :1waxlx*ASxix*Yw:CyL•*x**itx*F"ri kxxY:rx:xXxxxzxx:*z%�w•x;;xY##*sxz*YxYFwxXxxY#xxxtw*xe*txw <br /> 22 049 12/88 <br /> LING ZNSTRJC'IclNSz FOLD I4 H.4I.F AND STAP�.E, AFFIX PROPER POSTAGE, <br /> t S"-4 JOAQUIN LOCAL HEALTH DIJ'Mcr <br /> AMN: WDMIG[MM TANK PROMMM <br /> a. 8. 80X 2009 <br />