Laserfiche WebLink
• APR 27 '90 14:24 R.H.L ACRAMENTO 9166464679 <br />P.3i3 <br />SAN JOAQUIN LOCAL <br />HEALTH DISTRi6T� <br />UNDERGROUND TAW DISPOSITION TW44XING RECORD � <br />SECTION 1 - The San Joaquin Local Health <br />District's TraL ` ��ALN�EPLT! <br />will accompany each tank affixed with its <br />The Tracking Sheet is <br />site identification`nnumber. <br />to be returned <br />District within 30 days of acceptance of <br />to San Joaquin Local Health <br />the tank by disposal <br />or <br />recycling facility. The holder of the permit with number notes] above <br />is <br />responsible for ensuring that this form <br />is completed and returned. <br />FACILITY NAME: <br />FACILITY ADDRESS: 3-T),�; ia�� Y SRP��(�jC� <br />TANK ID #39— t -7— <br />SECTION 2 - To be filled out by tank removal <br />contractor: <br />Tank Removal Contractor: Ft ��,.1 -R. 00I~0, <br />1k., LrV. k <br />Address:�,e`aphone <br />.#� <br />Date Tank Removed <br />SSMON 3 - To be filled out by contractor "decontaminating tank,: <br />Tank "Decontamination" Contractor <br />Address phone# -- <br />zip <br />:Authorized representative of contractor certifies -by signing <br />below that the tank has been decontaminated in an approved manner <br />as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <br />SECTION a - To bb filled out and signed 'by an authorized <br />representative of the treatment, storage, or disposal, facility <br />accenting tank. <br />Facility Name Gig r S a,� 11 <br />Address 55; , Phone# <br />ip <br />Date 'Tank Received 91902 <br />AUTHORIZED SIGNATURE AND TYTLE <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />A'ITTN : UNDERGROUND TANK PROCRAM <br />P.O. BOX 2009 1 5TOCKT®tV , CA g9201 <br />