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s FA N J C]l' TI N r_.acx ,L H Bix,7r' n i sox- x CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RkSiQRD <br /> #*#�#t Tl�*�'��A#k��t��**fi1tA:l2'�**t#twtitw*tttfX##*it***it*wlFftM�#w11�M#*�AtAA#AwAA#A*AAAMAIIM#IY14#A###�**Cllr <br /> 8F'".7%QN r - The Ran Joaq.zin Local Health Diarxict's Trarvjngl�, -set vill accompany each tank <br /> :fixed with its site io.lntification number. The Tr.- 19 Sheet is to be returned to San <br /> 4 Leal Health District vithin 30 days of acc:e ..-e of the tank by disposal or <br /> i . ;n ling facility. t"Umber M <br /> i <br /> :s�'.IT.ZTY ADDRIs.SS i 1 r r� na <br /> C� j i /r <br /> �x***wwwww***xxxerw�r�cwwt***,�w****wsw**wwwwxxxr�w*w****xx:rL,kNK -ID l039- <br /> r�rx*�'�***z:xxw*x*w�rw <br /> SEGTIOt4 - 2 - To be- f filled, out by tank. removal contractor; <br /> Tari Removal Contractor:. —. _._. <br /> y <br /> zip <br /> �. . <br /> Address., y � ,(�,:,.�' or• (' • h <br /> ` Phone I <br /> Tele phone; t ).- r Date Tank Removed' - <br /> �F xxa'axts�**www*wrix� -' •+ww*wwww*a�rxxwx*www*:t*x**x�t�rxww*rt*�;*w**irx�r**�fi�$��C���1C��Ci��C�l��k�f��i#i�Y�'� <br /> ww. ►Ix4VIlbLOVLV//L�� taWl[1�4�('iC� <br /> `rank Decontamination" Con ractor t <br /> S <br /> ` �dze:s8: �� 1 C),' Zip: <br /> A <br /> } Phone#: - - <br /> {i '' that- <br /> Autizorized representative of contractor certifies by sign�ng be lo' w <br /> decontaminated an approved mar,rje a as may be regulated by 'bepar�ment othe tank has been <br /> f Health .Services'. <br /> ( SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative,of the treatment- <br /> stowage, or uit, 1 facility accepting tank.. <br /> Fac i 1 i Cy i�amE <br /> �,i <br /> Zip: <br /> Address; r <br /> Data Tank Received: <br /> a, <br /> } jjjt t x zW 5 ATJRE AND'TIITLE <br /> � x*w********,r,rxx�rxxxwr�ww******�rx�r*xw**aw*w*,r*x�rxx*�e**w*x*xxx*wxx**x*w*.wxww*xxrxx,�*xwww**x**x a <br /> EH 23 019 12/88 <br /> MAILING INSTRUCrION3: F= IN HALF AND STAPLE. - AFFIX PROPER. POSTAGE. <br /> SAN. JCAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UMMCROl11+iD TAMC PROM M <br /> P. 0. BOX 2009 ' <br /> STOCKTONt CA 95202 <br />