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w®1 �'( 'g .+'+gyp <br />r..,Y i�...O •`i J °�' isAAl+ Icer eLTa Rs .4 L. i <br />h�I#R RRARfr�Er�ki��Y9K1kf47kSNk�t�C�cMtARRRRkA�rRk#it9tR'Afk;t#��r�k44kirtl&�rSiRR�t1F'A�4A�kaCR���tRRRA�trp���*R*&p�RtY*��hR•RRRkR� <br />e�aEt"'I'ION 1 - 'I'Yie Sats �c�acluin Local Health District's Tracking Sheet will arc:oulpanir eaCch tar+. <br />affixed with its site identification tri idv.r. The Tracking sheet is to be returta,-'d to Sari <br />Joaquin Local Health Distt:i b within 30 days of acceptance of the hank i:ry disposal or <br />r ec.yc i i rig facility. 114-. f4lo� &_.���.� �P..�!Q.� � � ill. �,t�l� " " ���1. :�..,-i. <br />FACILITY NAME: <br />TANK ID 839-° * <br />�'*RRRRkRB'**liiklk:t*RRR:IRfi'RRR�:pikl:�tA�ll�91��1�{'S�R�I'�C'k:1q6A'�'1F:t��l'Ik�i�C�l�'RRS�Iit'k]t71itA'���I7t�$]4R4f�IfR:tY�Cih'�lkitiAll�Jd'A'S#*lk:kRR*�l' <br />SWrIC)14 - 2 -- To be filled out: by tank repoval contrcac r: <br />I <br />Tat* Removal Contractor: � e <br />71��: 5 823 <br />Telep a NG: 6 / aN374 e Tank R�i Bfvor" rw ... .w.w wwa w.. .�sa�w +w. •..�a rw nw K... w«wti. ew. <br />RiEilkiFt��r�i�iAtF/AirhRAc�ltkRRRAtR'RrytllkitRfi*A'��kR9tR'�t�tiPtkR��t�rAAR�tltttf�Ak�t9tRlt�k�iAN�tA�YfcVtRR'R�cA�pRttt.•14*kr f�RArt'A'k$tRRRR� <br />Shutt k 3 -To be filled out by contractor "decontaminating ". <br />Tank Decdntarainatisn," Contractor: <br />Address: PONOX <br />V15 - <br />v . r <br />' —Plrone# s c <br />Authorized representative of contractor e.eztifies by signing Le -low that the tarje. to,3s L*Ln <br />decontaminated in an approved sua'nner as tsiay be regulated by Deepartmnt of }tealt:ia Services. <br />SIGMIUM MD TITLE <br />*hAR�Ckk�9t#*itkYtk�k�SRRRR�C'k�CktciE'hk�k�CirkkitttArtA�i7kk:kkAXdtltst'�k'*tkkfiRRk#iF�R�Ck�RfcRii�rxAk�kk;�RAkRkk�k**tt4tYrA'�Fk <br />SEC.*I'10N 4 - To to filled out and signed by all aut:hQrized represnetat:ive of the txeabtiant~. <br />storage, or disposal facility i accept: ing nk . A A <br />_.AMNOW <br />' <br />Address: <br />�• ?3-923 <br />e rer, e e <br />1Phone8: 2 p <br />Date Tank Received: <br />e. <br />AU'r HORI M S IGNA,1U M AUD TIME <br />*AAfek�tstx'R,4itRR*RRkSMA*A**R'R�kARR�k*itRRiFRRN�tRRAt�tkRYc�Cxri!*k�tRRk�iRf�A�c7RfiA�A'**tl•itleYtRRAtRftsY7�RR�&irAckfi�klt�t#ik <br />Ell 23 049 12188 <br />MAILING INSTRUCrIUNB: FOLD IN HhL.F AND ST.APM. AFFIX i'ItcA)E t posq (M., <br />ONy�}JOAQ®UgpZ1pN+, OZ 'rt TAW tIDI�S`rRicT <br />AA °e UNIJi�t(�t *16AiV8l Cha <br />�• Box 2009 <br />STPMIVN, C.A 75202 <br />w <br />