Laserfiche WebLink
NMI0 <br /> FACILITY NAME: l R-Re- ( T ),RAL --SQC 5tATIOAJ ��— <br /> FACILITY AL��S: ItTAW ID 1 �1 - <br /> UNDERGROUND TAW DISPOSITION TRACKING REOMD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> vith number noted above Is responsible for ensuring that this form is completed and <br /> returned. <br /> # r r ! * ! * w # ! ! * R * ! * # # ! ! r R * * * ! * # ! ! * # ! * ! SECTION 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: S m -Tk D.2 e 0; L� SNC <br /> Address: ) N ,Qec K m,�,�• FC&A 35 phone 020q).3 <br /> kZ Zip _9 5 0 /�0 357 <br /> Date Tanks Removed Q-1 91( No. of Tanks_ <br /> � r , <br /> =MON 2 - To be filled out by contractor "decontaminating tag*(a)a: <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tanks) <br /> has(have) been decontaminated in an approved mariner as may be regulated by <br /> Department—of Hea <br /> slc�► TITLE <br /> 7 <br /> SECTION 3 To Eilled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility aceept�ng tank(s). <br /> Facility Name SCHNII STEEL P 8Dvo.s C . <br /> COF1UUvP4 UA —142 <br /> Address RANCHO 918485.4810 Phone! <br /> Zip <br /> Date Tanks 01"ORI9BQ91$ of Zanks.. <br /> �OAIB 1'r08'IOd 00 o; <br /> ALMMIZED SIGNATURE AND TITLE <br /> tQILING INSTRUCTIONS: Fold in half and staple. Affix groper postage. <br /> EH N XX WP\TRACCS"T.LET <br />