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f: LSI J <br /> C),7\ I( <br /> 1'L? .r C. .1.' <br /> LRIDI72CStp ^'D T;'7K DISI'O^!'Plot! 1RArX.111G REOIXRD <br /> e <br /> *A'*****AA**A*A**.RAAA k**AAAA*****AAAtfA******A.tA A ***** <br /> SPY-1,1011 1 - The S:ui Joaquin ""ll 11• :11th Dlst-rl.cl:.'s TrW'1l ng Sheet will necoml,-nly rash tank <br /> alfixcd with Its site IdenLitir:<7ti011 IH"ubcr.;i "1hL Tracl;liq Shoet Is to be rel'Itrnerl In Sall <br /> Joaq,lln Local liralLh Dl.^•trIuL viihin 30 days o.i acrrptauc'e of Lite_ Lank by disl'osal or <br /> recycling facility. . nwnber tl Ld_below is reslxnlslble for <br /> ensuring that Lhi-s form 15-completed and r turrlec]L '1 <br /> FACILITY NAMES C��i• �r P 4Ll'1 1rA1 A, itt 'I!+ ' ' l'1 <br /> FACILITY ADDRESS:- 7 <br /> TANK ID 139---a-9A0-- -.Q I d0C4 <br /> ***AA1+***Art*A*AAAAAA* A*AAA,***A*' • ++.**A**A**k'. M1AAA A AAx*A+:A+AA*AAA*AA*A*A AAA A !AAA At*****A* <br /> SECTI(Al - 2 - To to f111rd c out by Lm1% re 'MI conLrartor: <br /> Tank Removal ContracL-or.0 ' 1 441 f 4 A.L5 '/10 is /� <br /> Address: bfS /J , Lp 1 f AL_ x C�e' J ^/' C Qr ZIP: <br /> - A / <br /> hone 1: 9'3 � <br /> Telephone: I�S1 / )_k3$ ^ �z�_Date Tank Removed: <br /> *****Ax*x***x*x**x***AAAA**xx*x**x***x**x******AAAAxx*x*AAAAxxx*x****xx*xx**x***x***x*xAx** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": ' <br /> Tank Decontamination" Contnra�ctor(�11 ' �� <br /> Address: _ v�� PIAaR CJ\�ll� r 1 � „IIA/111Yi�[� c Zlp: l <br /> `� Phone#: 4/-5 aJ5 / 39� <br /> Authorized representative of con ractor certifies by signing below that the tank has been <br /> decontami n a proved ma nee as may be regulated by Department of Health Services. <br /> 3I C71A 1 T 'L.F <br /> AAAA**k*****x <br /> SECTION 4 - T be fill d out and signed by an authorized represnetative of the treatment, <br /> storage, or d sposal cillty accepting tank. ' <br /> Facility Name <br /> Address: PALE Nv D ', <br /> YVtQ Zlp: / p <br /> Phone#: S15 a35 /393 <br /> Date Tank Received: �g <br /> dI�O ) <br /> ************xxx***Ax*x*xx*Ax***AA*AAAA**A ***I***Ri ****D*****kA**x** x*x**x*x***A**x***A*A**R <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL 11EALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STO IVN, CA 95202 <br />