Laserfiche WebLink
S21fI JVJ\0TJ11 '111 nIS711n1( ..•.L' <br /> Vi1DC[R(.I")! [ID ':'UK DISPOSITION 11W.V110 pruORU <br /> ^rr-rlcgl I. - The S •n Joaq+ain L++c:al llca.11h Di LricL's Tracking Sheet will accoml,my each tank <br /> ;'[fixed with Its :11:e It nnmler. 1 The Tracking Sheel: Is to be reUmned to San <br /> Joaquin Local IlealLh I Distr:i(_l: viLhin 30 (lays of acrel+t:v(ce of I:he tank by dirposal or <br /> recycling facility. jjpI _I(ulder_o[ _l.he hrrmlL_w1C�nim(ber. noted below is resixmsible for <br /> ensuring that this form is completed and reLurned. <br /> FACILITY NAME: yri,B> <br /> FACILITY ADDRESS:_�_��J Itl � CmrrA <br /> TAI1K ID 139- 13 (� �o, 60 (SAL . <br /> Swrial - 2 - To txi fill ' 1 out " In '. rem+ vnI coi(Lractor. : <br /> Tank Removal Contractor- �J /J` 9,4A).'5 <br /> Address: ( �/ tJ Jl rACI Com. Zip: 9.s37� <br /> Phonel: <br /> Telephone: ( .2091Date Tank Removed:__ <br /> **R*R****RRRRR*R*****R****R*R**R*R********k*R*************RBBB***RR***RR**R******RRRRR***** <br /> SECTION 3. -To be filled out by contractor "decontaminating tank": ' <br /> l �C;SIJyl _1(ly � i <br /> Tank Decontamination" Contractor: l ' , <br /> X55 `t�ARiZ &-qb R � <br /> Address: , ICt t'YlOU-1Zip: <br /> Phonel: _!L1 2.3. I 9 <br /> Authorized represell t of ntractor certifies by signing below that the tank has been <br /> decontamina n pr ved nner as ma regulated by Department of Health Services. <br /> SIcNA1URE Al TITLE <br /> *h***R***#*RR** R******* **R****RR************* *Rh****RR*******R****RRk**R**R****k****#*k <br /> SECTION 4 - To fille out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal fatfility accepting tank. <br /> Facility Name W C— //yy,ee,, p <br /> Address: S % bV 21p: U <br /> Phonel: <br /> Date Tank Received: <br /> AVI'I1fNR .F:D . IC71A1tRR , AND ITI,E <br /> *k*kR*********R*******RRR******k##*k***** *****k **h************R**k*****R*****R***R*R**** <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. ' <br /> SAN JOAQUIN LOCAL 1(EALT'H DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> ST=TON, CA 95202 <br />