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i <br /> S2LN .TCS. xXJ1 W 3.*(DC� I-r0ter.rrH DZ S'a`R T C 'rr <br /> UNDEFRCR 14D TANK DISPOSITION MACK I NG !� <br /> *ir*Y{ttakiCYt'lCYs*'lcIrycYtit*7t*x�k'�l'7k�1r*h7tt'****�k�t7k'*7tittk+*7kst*i�YrY[ski[�t�Y�1'iY**sYtkik�'k'Yt�k7k*7k�k7kY[�k*Yk�Klllktyi:4*�[YItX11r**11�7kk7C'+s <br /> SECTION 1 -- The Sale Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification numexr. The Tracking Sheet is to be returned to San <br /> Joaquin Focal Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. Tiehol of he r _fit with number not`d N�If2i� reppoMjblea for <br /> ens«r n 1,di3t _rhis form is completed_and returnp.(j <br /> PACI L.I TY NAM: <br /> FACILITY ABDRESS: _� r n_ � � C �) �t � t� (A-0 <br /> TANK ILS 939- <br /> 1tYcttYr*�IctAtkY[YtY.7titylr*rl�t�r�tYt**Yr*�*�rir***irYr**�*YtYttkYC�rx*�*Yrk���YaY**it*YC*7k Yr�c*�*�*YrYk�YkYrxCYtYSYr:t�YicYlr7t*Y;YrYt�IrYKlk*�>ti�r <br /> SECTION - 2 -- To to f i l led out by tank removal. contractor: <br /> tTank Removal Contractor: ;cv <br /> Address: w 12 5z GC% / s'T/vr _9� _ . . _Zip: %�J5 •� <br /> Telephone; ia� � ) � _0Date Tank Removed: <br /> Yr�k Yt*X**Y!*�*yk 7r Y;YM Y�"K'k*X*Yi 7Y*'lk St 7t lk yk iY** C at Ys lk iC YtYi***YS�7t Yk 7�#*7�'St*7�7t 1C'!'*�k'7t7R'Ik#*Yt rY***Yt s�YC�*Yc'k Yt��r Yr#SY�ic xYt Ylr*7k 7k iY/' <br /> SEC,T.40N: 3 -To be i ilted out by contractor "decontaminating tank". <br /> Tank DecontamInation" Contractor: <br /> AddYess: t .�l f/ /�i� l'/Y G II 11 5�� Zip: Z) <br /> Phoney . - , <br /> Authori7ed representative of contractor certifies by signing below tfkit the tank has been <br /> decontaminated in ,ars approved mznntte:r as may be regulated by Department of Health Services. <br /> SIGNATURE AO TITLE- <br /> SECTION <br /> ITLESECTION 4 - To be filled out and signed by an auttiorized represnetative of the treatment, <br /> storage, or disposal/facility accepting tank. <br /> Facility flame ^L_.r / Tr,7 G 5 � _� - <br /> a.(�.`3a�e�ua• F'' .' — 7,11:): <br /> Phone I - <br /> Date: Tank Received <br /> At. MORI ZED SbCNATU[2E AND TITLE <br /> *Yr*�r�Yrat*gat*Yr�r*YcYcY`YtkY:YrYc��r�r�*>t�**r�r**�*�r*�����*x*��*�r�*�t�rrr�r��r��t*>+•��rt*�r��*�**�Yc�r�* sax***�r er��r�rY: <br /> Ell 23 049 12188 <br /> JWLING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AUIFIX PZOPEN POSTACm. <br /> SAN tIOAQUIN rAC.AL HEALTH DISTRICT <br /> ATTN: UNOMMOUND TANK PROMAM <br /> P. 0. WX 2009 <br /> STOCKTON, CA 95202 <br />