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I JE <br /> PU_'t`31b__, ALT I <br /> SANjOrl(IUIN(:+. UN1'Y <br /> .,r 11 <br /> jOGI KIIANNA M.D.,MY 11. . <br /> __. Health Officer <br /> P.0. Box 1009• (1601 Fast Elazetton Avenue) Sco,,, ,n, California .)5:'t)Y <br /> ( 09) 468-3/ <br /> 2 - 300 <br /> [tyf xf UNDERGROUND'TANK DISPOSITION '1'(2A('IUh(; R?:C(Ti't1 ;?` �r 4fIEi" <br /> EI M]T i SERVICES <br /> !'r1 #+a•♦f###t##**1 R i;####**i##*######**####R##***#**#*####4*#'#t k 1 Y}t Y i#k-k t*t*k t Y'k*k i t k <br /> ` r 'SECr1ON , Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. 'flee <br /> "rrackin t Shect is to be returned to Public Health Services within 30 dais of acct Ttance. of the tank b • the disposal or recycling <br /> v S -- - - I y f <br /> Iaci!irr` ole permit holder i r sportsihie. for ensurinh that this farm is conipleted and retumcd. <br /> TW <br /> r I,.iT1' �. <br /> NAME' <br /> e� fit' <br /> i�A,:i1 1"1"Y ADDRESS: l/ <br /> laK. iD #39 - I � (.) ) _ Taitk.UescrilTtil.in - i -� _i_c_� a ,t �'t:.[�:;i'�• �rG(��) Arlo Lr��s �' i, <br /> t f t Y Y 1 f.*'1t#t i*}*##•:t#'t**i k t*T**/'#*##Y#t i 1##k}##t+1'.:. k#}'Y d t:±:}Y 1'#*'k###}'t#:t k w#*#-k'k II#*##3*#t*#k*i t!*t#R#*t i Y••s* �.' <br /> SF(,; 'l0N 2•- 'T'o be filled out by tans: removal contrrtctor: <br /> rrrk Removal Contractor: <br /> r. <br /> 1c1r1I u�S' _ .. r i <br /> �5�..✓w"r �." <br /> 1'Itunc #: -- '—`—�f --- [�a[c '(;rrth RcntcTvcd: ----------/�Z / -- <br /> '�•' Y+t t#Y t 1 'L�+k�R R Y**i*R*###7*t R t R##�Y p k a t?#**#'F R*#t'M#k t*t*#Y s#t k}'Y*#k t 1 t I t t a Y*t i k###t s Y#l i#T#t!f*t R*#****t Y a Y i - ! <br /> S1 Cyl'!ON 3?-10 he filled out by ac for "lecon 1,1111illating tan!:": <br /> �rnk C?�.contarnination Contractor: � :�„ i v, _��._�,_���+—_���(�_ �-�••- � �'- ' <br /> r <br /> City: _ � � `i�, ')i'1 Zip <br /> r I:. <br /> F,:j!i-,orized re of contractor certified by Signing bel wv thr it tiro laO, has been decontaminated in+an approved <br /> wanner as required by the State Department of Health Services. ; <br /> c!�t-!i[tire: <br /> ,;fir �'. f, t._i .' „l�r��l ' .._ 1::!'':— s„( «,� ✓ <br /> f,.,; -Yr�taR*i••xR#t#,MR####kR*##****�Y#*#*###t'ktt M*�Y 41k#4t 1+I i # Y1 kt i::Nt**k*#•kik#Y'k#*'k**#*####!!R#####*# (. <br /> SE t'i ION d - Tri be signed and dated by an authorized representati , of the treatment, storage, or disposal facility <br /> k` <br />�r2 acce tin lank and piping. <br /> MMMMFMIEI�77,7, <br /> _. .... . — Cit}': --µ�z''%:�'_-- — 7ip: <br /> p �r <br /> ,y <br /> 19 <br /> r <br /> ♦•.. , ,•r?!RaF R M'Y t y i#*k*#*4*#t t k#t 1 k i.'1 4 1 !Y't*:1 1 }'I' 1'± Y'r + I r t <br /> li <br /> F3••tf+9 (Rey 2181,11) .:p <br /> s <br /> A T>i•rsinn of San Joaquin <br />