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r° <br /> UNM. -40UND TANK DISPOSITIONIRACKING ..900Etp <br /> LckSECTION 1 - The San Joaquin Local Health District'sng Sheet will aa#fixed with its site Identification number. The Tg Sheet is to be�rett:rpany �Q..ganJoaquin Local Health District within 30 8arecycling facility. ys of aoaeof the tank by disposal or <br /> 2DAMing t at this form 19-Carol t9d and J&t=ned, <br /> V��> '. <br /> FACILITY NAM: ��/l �f�t <br /> FACILITY ADDRESS: Ve4i ,-TleiI q SLdj <br /> TANK ID 839- I�f_— _�_ <br /> * <br /> SWrION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: J c'! .✓ e'A J?i[ e:,r.C <br /> Address: C e e CI- VMIt-c- <br /> 1p: 3. <br /> Telephone: �' 3•- .r $' :,.1 <br /> ****� ��*���R: xved <br /> SDMON 3 -To be filled outby contractor "decontaminating tank": ^; r <br /> n • C f�R.d <br /> Tank Decontamination Contractor. /� Yr♦z sewf /e . <br /> Address: e`c `'cC ,/,�l/� Z1p: <br /> Phone#: ,,� k <br /> Authorized representative of contractor certifies by s fining below that the tank has been ., , <br /> decontam rued an approvedR <br /> r as may be regulat by Department of Health Servives. <br /> SIGNATURE AND TITLE <br /> w <br /> SECTION 4 - To be filled out and signed <br /> by an authors represnetative of the treatment,'- <br /> storage, or disposal facility accepting tank. <br /> FacilityName=A / G- ��''G e <br /> , �if G /rte/ y <br /> Address: ��1� �i�'� e 4 e,.Vt=C �f e, e.,.T'o Zip: <br /> Phone#: w <br /> Date Tank Received fi <br /> 4+ <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EN 23 019 12/88 5 <br /> MAILING INSTRUCTIONS: E= IN HALF AND STAPLE. AFF' X PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH PISTRIcr <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 952O2 D <br />