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MT .70-n Q?rT1. r Tlcv(=',Zl7a 1.1.131 A-1-:1'11 1� <br /> LRtp[RC�?CL�!D 'T7 11V, DISPOSITION 'AItACY.IPU RF.CIH <br /> ******x+*#x##*xx A.+h**hx�**#*x***x:?*x! A+*xx*h#"`'•!`**#xxfihx*f ,t#fi*#*fi**fi117YI1�11Ythxi kxxl��//!/txx x* <br /> SE(.'1'I(KI 1 - Vie San Jo:lquin Local 11evlLh OisL]-JCL's i :-•i:ing ShnA1 Iia..,ccczo e((a�rt tank <br /> affixed with Its site 10entiflcatiou numl;er. ; "the It ;,- ktng Sheet returned to San <br /> Joaquin Local IlealLh WrLrlcl: within 30 days of necr!PLr1nr_e of the tan G�c�� Wnt or <br /> recycling facility. The_holder f the 1McmI - wtLh number noted below is rC Bn b e for <br /> ensuring that this form Is c mhleLed and returned` " 't ' <br /> FACILITY NAME: 9"% <br /> FACILITY ADDRESS: 17 J_� /�11 Gn r rwL 1 1 Udl� ej i rwtt/ <br /> TANK ID 139-_ 13 C _,Ql_ 10l P60 CAL, <br /> SECTION - 2 - To 1.1e filled ouL by Lank removal cvW.xactor: <br /> Tank Removal ContracL-or: <br /> Address: �'� /J , C® r : � 1-1I Lta ItJ zip: X37(o <br /> Phone l: 117 <br /> i G <br /> Telephone: (e?a ) i3$-�S-6 Date Tank Removed: 5 " 16-p I _ <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": ' <br /> Tank Decontamination" Contractor:" ; QL�i�l^I�KSU(��,� II,tlQtn I p' <br /> Address: _0�-�1� �i9�� L !^YS�! $191 ! zip: O Q <br /> Phone#: '1'/6 OL ,s 1370 <br /> Authorized representative of contrac r certifies by signing below that the tank has been <br /> decontaminate i a ro ed mann as may be regulat by Departmgnt of Health Services. <br /> IG1A'ILIRV AND TIME <br /> SECTION 4 - To be fill out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name CQ <br /> Address: t� zip: ` (_Q <br /> Phone#: <br /> Date Tank Received: <br /> AIIIIf ZED SIG71AIT R AND TIlLe <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />