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TT1,r rKr% TA KR! rrlcDeTMTn.Ar 'PDAs T&111 DrY,-non . <br /> y,y yyy y.L y.L y.J..Lyyy. .y yf. .4.vy ay y�ay\.ti4RJ\v Jv..\41.4yiy yi yJay .vyy y.WlJa..sy yi yv aWN.W.yr..J.•y.{.a 4L.V4 Jr.•i'YLy/.4WJ.61.uL'Wyyy .y Y y y.J..4 y.Yy y.y W.4.yyyyy <br /> A�AiI�AA RA*AAAAA A�A�AP�AA6n�A AA*w,A AA AAAA��AA�A A If AAAa IA1f AAIaq Y A aA AAn�AAAAA�IIAA/a a laA Ia R/41A IaAAA4A� <br /> SECTION 1 - The San Joaquin Local 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 rmit with number noted below i ns'ble for <br /> ensu that this form is cam leted and returned, <br /> b'ACI LITY NAME: C- <br /> �.r� <br /> 0ACILITY ADDRESS: Li 5 p <br /> -TAMC ID #39-� <br /> 3ECr1ON - 2 - To be filled out by tank removal contractor: <br /> rank Removal Contractor: UERISH. INC. <br /> Address: 2905 F. Miner Ayp <br /> Zip: 95205 <br /> Phone#: <br /> Telephone: (__209 -3831 _ Date Tank Removed: To Be Determined <br /> 'ECTION 3 -To be filled out by contractor "decontaminating tank": <br /> tank Decontamination" Contractor: <br /> address: <br /> Zip: <br /> Phone#: <br /> authorized representative of contractor certifies by signing <br /> tecontaminated in an approved manner as may be regulated bDe low that the tank has been <br /> y Department of Health Services. <br /> SIGNATURE AND TITLE <br /> ;ECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> itorage, or disposal facility accepting tank, <br /> Facility Name ERICKSON INC . LPA I . D. NUMBER CAD 009 466 392 <br /> ddress: 255 PARR BLVD. , RICHMOND, CALIFORNIAZip: 94801 <br /> Phone#: (415) 235-1393 <br /> ate Tank Received: <br /> AUTHORIZED <br /> *�*SIGNATURE*AND <br /> TITLE <br /> �r�*�r�c�*�f�****�c**�r�r�**�*�**x***� <br /> :H 23 049 12/88 <br /> AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> AT N: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />