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:.:•.mro.��.r.:.nm mew DI^_O!-1�r.n�nr, *o n..",t r�'Ci ,�...w,:�.:: <br /> #%x%2#xXrixXX}FSFt%X#xYY}*'kZ#:C:C;22SYzriZ*#3Y#Y#YY:CF*#XSXriY##F#XYY#ZZ*#####XXXZSZxAIf#};#X#2. <br /> ION 1 - The San 3oauuin Local Health District's Tracxiay Sheet will accompany aac: tank <br /> fixed with ;rz site identificsc:on number. '"he zac?inq Sheet is to be .returned to San <br /> aquin Local 'r'ealth Dist:ier within 30 days of acceptance of the tank by disposal or <br /> cyc'_inq facility. 7ne_1o1der of the permit with number noted below is responsible for <br /> aur.'_na thac„ l!L15 _ form is cnmolst%: and ,returned. <br /> CILITY YA!G: � � TV1 <br /> CILITY ALORESS�:p3� 10�� <br /> NK ID 0]9-__Z/ <br /> k##YFXYY#�'AXx>.Y#Yif:CZ#F#FZZZ###F i#YYt:t#:t# ##AZ Yz�k Y#Yt#*it iCAYf k e�F:11* *Z#F##=A;YX}YYASY%Z�r <br /> c:' 10N - 2 - To be tilled out by tank removal contractor: <br /> nk Pamoval Contractor: 2?°RiSH, INN. <br /> are s : !.:_3 F. Mine: Ave. --Zip: 95205 <br /> °�.orkton. CA ! Phone#: <br /> lepr:cnc: ( 2Q2 _1 466-3837 Cate lank Removed: To Be Determined /D-l2 -fr9 <br /> .iZF#X#xZ#X}#X'rif1**#f'#ttXZ*ti*kh##�rZ##ri ZKA;Y#Z#XYI'FYYYY#Yk ZY YZYC#Z?#T.ZA#7!W#7t#]t##ZFXA*;;*7k 7tY*r <br /> yII�^C! 3 -Tp be tilled our by contractor "decontaminating tank"; <br /> -1k U:_ontaminationo Contractor: <br /> 3ress. Zip: <br /> Phone#: <br /> :•hOtizrd :4�_:rFsent t:vr. of co::cr,ctor certifle= t signing below frac the tactic has r+!er. <br /> nun anr;•:vcr: sz.nner a:, May be tegelated by Depar'•mznt of Health SGrvices. <br /> SIGNATURE AND TITLE <br /> %S 2 F:S['£.'.'2'3 Y'X:(Yi':ktt%'t4;9#K ASA7e4XT7t ttr#T.#X7#YSY2 YYZF ##Y#YYY:t;#;#Y##*#.**##2*YYFF%FXX##xf2 <br /> signed by an authari.xeC repreznetative of the treatment, <br /> .)raga, Or d;32rcil-ty a cept.nq Lank. <br /> :ility :;ama ERICILSON�INC. EPA I.D. HUMBER CAD 009 466 392 <br /> Press: ___155 PARR BLVD„ RICHMOND, CALIFORNIA Zip; 94801 -- <br /> Phoned; (415) 235-1393 <br /> :a Tank Received: <br /> .i*:#SY(z'ASzx###Fe Chi x#WY:c#*Y ns�i i�`Y^�*xz�k,YDz S1GVATW,ZLa7:t*AuD <br /> 23 049 12188 <br /> LING INSTR!.=jCAYS: FOLD 24 WNLF AtM STAPLE. AFFIX PROPER POSTAGE, <br /> sxf .IOAQUIN LocAL HEALTH DISTRICT <br /> V <br /> ATTN: WDERGROUND TANK PROaMM <br /> P. a. BOX 2009 <br />