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0 <br />*x*r**ftyk*yid'$xxR'7k*1kX#xx*'**,** ****ItSrv**ktxzx*It y *******'z <br />SECTION 1 - The San Joaquin Local H":lt.h District's Tracking sheet will ac -company each tank <br />affixed vith its site identification number. The Tracking Sheet is to be returned to San <br />® Joaquin Local Health Dlztzict Within 30 days of acacptance of the tank by disposal or <br />re+=yclinq facility. Mg holdej of thtt permit yith n r noted below is Fesoon-sable For <br />e,�T iMu D2. tbat this_farm is co gt ¢ !jrg-xeturned, <br />i MILITY ADM=: 124 W66t EIn Street, Lodi, California <br />TAW ID f3-- 15 ,do- <br />*VA-XXXVWXY*'X7Kx'i***-z al t*Sz**1r":& C7f*ICRr:rY�*Y�t�tttX*ig*7�::�exrxrxx**t�exxx,r <br />SECT ZCN - 2 - To be f i fled out by tan}: remova 1 contractor, <br />Tank Removal Contract= :Aneriean. Eavixonmental Hanalemant Corporation <br />® 9719 Lincoln Ville e Drive Suite 50: <br />Add.res:s: g Zip: 95827 <br />Sacrcmenzo, California Phone: (91 <br />Telj3pk"r,s: ( 916 ) 364--8872 _A3te Tank -Removed: 24 Al"m <br />*x*otxat:kx�t#**7kx**ick****��kzt'rx*rtir**#:kx�tir*zxrr*rxAit:t*r*rf�z:rxxrr:x�t*zr�rx*at*x*r:tsrxrxir�: ici�ric*�r* <br />SE "I0I 3 -To be tilled out by contractor "decontnminating tank": <br />Ta..: De�.,at;taminati.on" tza.^tor: � C <br />Addre : t/- : �` t �j <br />Zip: 7' <br />Authorized representative of contractor certifies by signing belov tit the tank has been <br />decontaminated in an app~oved manner arcrsay be req latad by Depaztment of Health Services. <br />SIGH AAD TITLE <br />xM',##+R#*R*Yt7ttlr�Etir&#trzs*x:r�ntrzxxx**xx##�k�:xxx*xr*xxxxtx:r�:*xtaxr#*t*xs�tcxxxxzz*x:cxx*##xz�*�rsrxz�e# <br />SB=.ECN 4 - To be filled out arra zigrj--d. by an autharize repre$netative of the tzeatroent, <br />storage,, or disposal facility accepting tart,k. <br />Raw Erickson, Inc, <br />Addze!is 255 Parr Boul4vaard ziP; 94801 <br />® Ricbzond, Cazl.l.fo:nia <br />In• , ! ins <br />Date 'lank ived- <br />J <br />AL)THMIM) SIcN47Jei AND TZ. <br />**7c#*rtY&**zxxszxi:** ftp*f.*text*-7CYtxlc*xxki;**tSricr*�c7r�*xicir**�t+�*y�**-*szxx7tSYcfxxc:tst7Cxxt*kfcxkzYcx:kx <br />® €H 23 00 12/88 <br />',"•AIL•i4Ci IiISc�U�^';'ICd7S: ECX.a IN HILF° AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOP: U 16 tit LOCK, HEALTH D i S'iRi CT <br />ATTN : T-NECKR0UND TAW PfZ7MAM <br />P. O, BOX 2009 <br />ST0CKTCV, CA. 95202 <br />i <br />E <br />