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MMMM� VNK DISPOSITION TRACKtW, <br />�R'XltXtt*xxx2X*X7t*7kx!!�t*'X'*tR7CtS1X*tt:tx2Yh'9tf2'R*RX'?*7e 7k*t*A'xXZLt**X7kxYaxrlt7t7CA'�kTssY*7kk�tt*9rxt�tkXX <br />SE'rTIi�N 1 - The San Joaquin Local Health District's Tramming Sheet will acecrnpany each tank <br />affixed with its site identification n=ber. 'ihe Tracking Sheet is to be returned to San <br />: 3oaquin Local Realt:h District within 30 days ®-f acceptance of the tank by disposal or <br />zec.-ycting facility. holdg; o` the MMIt with number noted tx_-�w is responsible for <br />tuz:ing that thin -form_ is CofojnilarAd :and -. <br />® FAC;iL]TY a ge 124 ;Jest Mls Street, Vii, Californis. <br />i <br />TANK I D 139--;... <br />*zxxzso2*xxxxxxsx**iryc'xxltx�t*xsx*zttx*�rxX�t�f�•**artY**:rxxxzx*�*x�:%Rz�cxxxrxxr***xxxx�: xxXxx;rxx <br />SMTICN - 2 - To be filled o;jt by tarn: reioval contractor: <br />Tank Removal Cont;ractox:American Environmental Management Corporatio-a <br />® Awress: 9719 Lincoln Village Drive, Suitri 501 zip; 95827 �- <br />stramento, califa~n'La Phone#: 516364-8572 <br />Tei�3ph�a:se: ( 9I6* ) 364-8872 Date TW* ReaOctid: <br />*#:4:t**:kip*txlxYrx7��'txxzxx•gx'#xxx�Yzt7rX9sxx7rxxtxzlY7t*Y*x'!xt#:e**XR9t***xYSxrxXlkY'gxx**x�CYxxye7i'ytsyr7r;k7: <br />® SEC'CZCl�f 3 --'To be filled out by contractor Odeconiaminating tank°: <br />Tani: rn:contamindtion" Con't':actor: <br />Zip: <br />® Autl.orized representative of Contractor ceztifies by signing below that the tank has been <br />decontaminated in an appzoved ma..iner as May be rec�,�lated by Depa.�-trnent of i:ealth Services. <br />3lCfite+�ilR.t: ).- <br />ZND TITLE <br />x:txxx�i'�x*xzx*fit*x*k#it*rxt**ist:L*?rlrt**#*�c*tri:**z•x**ic#*#*�t*x*xxxiti;xxxx*is*xrtx'xx•�xxkx9:i:�r*r:scxxxxx <br />® SECTION 4 To be filled out and signed by an authozizevd sepres,netative of the treatment, <br />stora e, or disposal facility accept- tank. <br />, <br />Facility, Name Er icksoa, Znc. <br />e e�st.ss; 255 Parr Boul*yard z' 94801 _ <br />• <br />Richmond, C&:if orals: Phone # : lq/,(- <br />Date xa, R,,. eia. CW�L �1911 <br />_ <br />AUPHC*S1ED SIGNATLRES WD TIME ) <br />7kXAr$�l'R*l:9r*ir* h!t***t*fit*�t�t****7iirt�istkifrAic:#3*s!**iktyF*k*ictt}r**�k*�kx:kyc�r%*�tycxsic;tX�t�tXXX7cXX*xx*kYcX7PY <br />• W1 2:P 04,9 12/$8 <br />MMLING INSMr-TICKS: FCh.D IN IMM W) STAPrX. AFnX PROPER POSTACv. <br />SAN JOAOUIIJ LOCAL W-ILLTH DISTRICT <br />MnW : M) GRAD TAW PROMM <br />P. O. =C 2009 <br />ST=x, (:4 95202 <br />r] <br />