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.1C�2•��c .1D T�Nd DISPOSI_ICN -!L- =121G ?E--2Z <br /> xxzzxxxxzxxxxxzxxzxxxxxxzzxxzzzzxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx�cxxxYxxxxYxYYYXxx <br /> SECTION 1 - The San Jcacuin Lo�l Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local. Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the oe^ni+- with number noted below is responsible for <br /> ensuring that this form _s Tomr_ a*ed and -eturned <br /> FACILITY NAME: �G rh S -Z-V1 C_ <br /> FACILITY ADDRESS: <br /> TANK ID #39- <br /> YYYYYYYXYYYXYYYXXYYYXYXXYYYYYYYYXYYYYYXX XYYYYYY YXXYXYYYYY X xYYYYx Y�7t:tYYXYYYYXYXXYYXXXX <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Parrish, Inc . <br /> Address: 3128 E. Miner avenue Zi 95205 <br /> Stockton , CA Phone#: ( 207T-777=1 <br /> Telephone: ( 209 466-3831 Date Tank Removed: To be determined <br /> YYYYYYYYXXYYYYx�tzYYYYYYYXYYYY�tYYXXXYYYYYYYYYXXY:txXXYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYYxYYYYYYYY <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> 'Sank Decontamination" Contractor: <br /> Address: <br /> Zip: <br /> Phone#: <br /> Authorized 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 Servides. <br /> SIGNATURE AND TITLE <br /> XYYYX1tXYYYXYYYXXXXXYYYYYY]tYY]tY:tYXXYY�CXXYYYXXYYYYYYYYYXYYYYYYXXXXYYYYYYYYYYYXYYYYIYXYYYYYXXX <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> YYYYYYYYYYYYXYYYYXYYXYYYYYYXYYYYYYYYXYYYYXXXYXXYXYXYXYYYXXYYYYYYXYYYYYXYYYXYYXXYYYYXYYYYYXY <br /> 8N 23 099 11/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER pWTA(Z. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAMC PROGRAM <br /> P. O. BOX 2009 <br /> ++ STOQCTON, CA 95202 <br />