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T'H DZ'STRICr "L <br /> =Ma?C 4D TANK DISPOSITIONCKING R�. <br /> -.* <br /> •xx�x*�r�rx******x**�r*******************�****x�r***�***x �**x****x***x#***�x*******x**�**xyar `'`�' • <br /> SECMN 1 - The San Joaquin Local Health District's acking Sheet will <br /> affixed with its site identification number. Zl.� Ttr <br /> cking Sheet is to"be roSnLocal Health District within 30 days ofce prance <br /> of the tank dis <br /> recycling facility holder of the ner bY•. posa <br /> - s - orm -- -- - - <br /> - . 7 } <br /> t l a <br /> FACILITY NAME <br /> FACILITY ADDRESS• <br /> TANK ID 139 . 0/ 6��°�' v �1'� -- / ' _ �j !�o/ �f ll�,.�v'!tc •,I- <br /> •**7k***fit**�!** ***7k*�!***'!t*7t****74It*!t**IM**1k*9:****7t**7k*'*** <br /> SWrION - 2 - To be filled out b - _.. <br /> y tank remava1 contra or: v Y� <br /> s.rtw <br /> Tank Removal Contractor: <br /> W - _ <br /> , S_f c•%.,:�' e 7?of <br /> Address• f" cl <br /> l fi <br /> i.C• G i a - ... 'r��a a"` � - bti w�„ <br /> Telephanei 4-Data Tank Re owed: ..•_ ;Yx ,ter ya ,S <br /> *XX*ir*lt*lh**arlMarx*iter!!*�rlk�t*x*itl�ik## ' M { <br /> SEfC'i'ION 3 -Tubby contractor "decontamitin y,ark <br /> . .+ •f y Y Y:'v��ur F ]1'F�2 ` .h`jA .1 W '+tCd^-«7tQ ^'aIt 9; c,1 <br /> �,y it ctor• �+/�,r' I IC�.�-' C l /./['3t� 7 l 'C�y 4 r �: y'M1 �"v`e4}y'�" _ <br /> y�,/�.�a {AI� `���� • /— � •«� ��C'f�. !..:J�/4 i':��' ;����tc 'a�ist{,t 4�Ctt �, `LA r°-•`� f <br /> MdresS: <br /> attr � <br /> Aut}ivrized *e»r�aerit-at.+ve of contract <br /> or certifies b si in below that the to en- <br /> en { , ,; <br /> Y S" <br /> deeontamirtj. in an.approved er as may be regulat by Department of HelthY S4r+rict:1 < r`"� <br /> Ile <br /> siwktm, AND TI <br /> !!'�:*�7t'k*•***1k*7k'kyC*yl'ick,*:tit*it**tt7t***7kykyt**itit*ft**x*it**!!fk*!k**!t 7F*1t*!t******!k******!k*it*1t*1i'******fit*t�**' F1R�4i''r l � <br /> SBMON 4 - To be fUled out and signed { <br /> =story by an' authors represnetative of :the tre�ti�ent; <br /> ge, or disposal facility accepting tank p y <br />"Facility Name <br /> , ,, <br /> 7 <br />'Address: •� �'J f�2�/'�� �:it��5. "L-'�. //'G/1+''�/�f C-✓ G� :. � r��y S �� k���� r <br /> Zip <br /> Phone# <br /> Date Tank Received: <br /> Lek _ .�•:s.��;�...14.� 7* rit' as <br /> ALM710 I'TLE <br /> LH,23- 049 12/88 <br /> FILING 114STRUCPIONS: FOLD IN HALF AND STAPLE. Am rx <br /> SAN"JOAQUIN LOCAs•, HW-TH DEVI <br /> ATM: MDER ROVND TANK P ommm <br /> P. o. BOX 2009 MAR 1 s X89 raK; <br /> STCkMCTON, CA 95202 . ENVIRONMENTAL HEAI.TF�' <br /> PY <br /> PERMIT!SERVICESC(O <br /> 4 ski <br />