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FACILITY KAM: ikjtI .1UL'L. <br /> FACILITY ADDfiIS:�1 �'�sisSl.�11+ _S.�L 3�z Tllt+ff( ID 0-:3-9-- 1 B Y C,z. <br /> TAM DISPASITION TRACKING FdMO tD <br /> This form is to be returned to San Joaquin Local Health District vithin 30 days of <br /> acoeptance of tankts) by diaposal or recycling tacility. Tfia holder of the permit <br /> vlth number noted above In respamible for ensuring that this form is completed and <br /> returned. <br /> To be filled out by tank removal contractor: <br /> Tan4c Resoval Contractor:_ -Tt •t c __ <br /> Addy can __y f„ k tie f3 �'p Phone <br /> Date Tama Pim ved No. of Tanks <br /> • R * * * • * ! * R ! * * R * ! ! ! A * R * R � R * ! * R R R * * * * <br /> t t <br /> " MSMLON 2 - Yb be filled out by eontractclr "decontaminstIng tank(s)": <br /> 'rank "Decnnta ination" Clontractor_J-'m T41)ex e D.IL <br /> Authorimed representative of contractor certifies by signing below that tank(s) <br /> hwlhave) been deaantaminated in an approved manner as may be >Gegiilatad by <br /> Department of <br /> §1 Q AND TITU <br /> * * R ft * �* • � * * * R * * R � R R R A * R * * t * R ! x * fr ! <br /> SeCrIOH 3 - 16 be filled out and signed by an authorized representative of the <br /> treatment, atorage, Q disposal Licility accepting tarn(s)_ <br /> :,%:NNITLEWSTM RROJ i:.,.. <br /> w, Fact 1 ity Mame 12000 FOLSOM CU.., <br /> MqMM <br /> -`-"- ` - <br /> VORDOVAUN-7 <br /> Address 1,�®-s95-ae'�c� Phone# <br /> -zip <br /> Date- Tar&3 Rece A No. of Tanks--L--- <br /> LN <br /> an s_-L—L. MULING INSlRPMONS: Fold in half anij staple. Mfix proper postage. <br /> of N XX VP\TRAG'>litl.Lar <br /> i� 71,E <br />