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FP.OI! P . : i <br /> Z)ISU Tarr <br /> . WpRt MOWD TAMC DIsposiTION TRACKY1tiiG RECORD <br /> wx*�*sa�F�k�i�l����r�1�1��k��a�:r� *�x*exwtttxxtfx**xxx**�**k�rx�rww�°wwww�rwewrr�eewwer� �� <br /> SP�IUN I - The San Joaqjin Local Health Disrxictla Trark,:ing " ,eet will accompany each tank <br /> ;red with its site ld,'ntification number. The Tx; ��iq gr eet is to beE '�tOL n-TH <br /> -again Local Health District within 30 days of accept.=..xze of ;,the tank by div 11/bFViCES <br /> f- <br /> I -:. iing facility. 4, t11D�-na f' --below is responsible for <br /> lu <br /> xAwl <br /> / <br /> CILITY ADI 3: <br /> t irt�C ID ��g— •-[�-��� �t <br />'4 �'*Jt�k**,'1k1k�1'*1k��9C9klk�7t11t�tk*�itlk�lt#Y7k�t7Myt'!k*!E**st"k71'dK*1!'�k�Cit74�1!'1k*ir'R�7t7tlC�t7t�itft7k**�a1t7k7C�Fltlk*'�Ikytlk*ft*]kx�kY��4*�F�[*iC*fit <br /> k SWrION - 2 - To be- filled out by tank removal contractor <br /> Tank Removal Contractor:— 1 <br /> address: 2i <br /> p <br /> Phoria : -�.5. `S9 3,5 <br /> Te leorse: Date Tarn Remraveci <br /> •••.�+..-.. ... .... .✓b iiiy4^... vu� Lj %.L3AU&CIL-U& '-µG'6-V1JL,AWL11aL&nY UdT!K" <br /> `i'ark D--ccntaminati <br /> On'� u7iit IotrtuZ'. <br /> Address: C�_ 1 �.� ,oa �� '`Cr <br /> ., r ..;..� ,._..�Y_rn�r. ��?,7 -- zip: �- <br /> r <br /> t Phone#: <br /> 4 <br /> I Authori7Ad representative of contractor certifies by signing below that the tarn has been <br /> decontaminated an approved mayar,t�Y as may be re^ulated by Department of xealth Services''. <br /> SIGNATURE AND TITLE ' <br /> SDCI'ICN 9 - To be filled out and sinned by an authorized represnetative of the treatment, <br /> stozage, or 6iz,-o* j. facility accepting tank. <br /> Facility NamE <br /> Address: o. .�. ' Zip: <br /> `t ...,..,, Phone#: O oV <br /> Date Tank Received,, <br /> AU'11iLu i Gni} s I cvATu1 AND TITLE <br /> E yyyy yyyyy .a .y +iyyyyyy y1 yy ya +y ay yy y` <br /> - <br /> EN 23 049 12/88 <br /> MAILING INSTRLKTiCUS: FCx.D IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOMUIN LOCAL HMTH DISTRICT' <br /> ATM: t1Nb.ERGROWD .TANK PR=2AM <br /> P. 0. BOX 2009 E , <br /> STOCKTON, CA 95202 <br />