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f� ; y 4Jr1: h7 LCJc �`1'K ICT <br /> TANK DI SF US'!`. IDN TRACK I NO R OORD <br /> SECTION S''�+�'hlbltlf Jy7` OCNI Health Discrlat 's Tracking Sheet will accompany each tank <br /> afEltfi1F1. •7C8Iit ; i7 �ation number ,, r <br /> toeSNin? He81th{�ifitif �`*yl thin )0 Aay9 0> acC ptancegofnthe tank eet Is ob� returned to San '. <br /> ttlCy�1t11 iity� �Ar;:19____at .��E 'the earmit � rn r` r nut�� : Y disposal or <br /> FACILIT „Nor-Cal <br /> FACILITY ADDRESS 1, 1eo0 <br /> TANK ID <br /> N39-' ld Z' ID�Dot> <br /> *kkRRR#RiTit �"#'#'�*RBBB#xkR#RRRRkRRR*R********nAAkx**7r�*fix****Ilk*kkfi*xx****kRkk##R#R#xx####xx <br /> SECTION <br /> o`rx lllled .'Out 'hy tank removal 'Contractor : <br /> Tank Removal:Contractor1 <br /> s <br /> Address[ _,M,r ` <br /> Z 1p 1 9i 659 <br /> PhoneM1 <br /> x s wW <br /> T1ephOnd ) F5� kap pate Tank Removed ; [ - 3 - C' 916-652-5515 <br /> *RRR*#RRRIF7.L tt #R#####R#RRR#kRRRkkkRx**kkk***kk'kRkk*kkRk*RRkk Rk*x*k*kxk kk*k#R##R#RRR#RR#RRx <br /> SECTION 3 �d be 1111ed 0Ut by contractor "deconCaminatinq tank" : <br /> s Vit, <br /> Tank baLb ' ,r% 'e r;l ceI <br /> Y .gi ¢a t i ''n �,� r} • ? <br /> Addreaar` yeH <br /> t <br /> a r: 90fi:µ.l7o T.nz�r a Zlp[ 95650 <br /> PhoneN I <br /> Authorl2ed °Ytl� esflfltativd'blti Contractor certifies .by signing below tNit the tank has been <br /> deconta In n app ed nner s may b6ZVdgulated b De <br /> partment of Health Services, <br /> k 'x ,x' 1 x4' A r •t. '91+ ATURIi 11ND TI <br /> kkxRRRs[RR [i1�R'�+CR#�+[R i�" ilk lt�R*kxRRkkRRkRxRRN:RkRRRkkkR kxk kkkkkk*Rkk*****xRR#RRR#Rxk#R#RirR �,. <br /> SECTION a li vlitld� dtt`Csandl Signed by an,4Ur.horizecJ re rosnetative of the treatment, <br /> stocagelr'.q! tfispo9al'fadIxty _Accepting tank , p <br /> PRODUCio ;oti• a ; <br /> ZIP) <br /> Phone [ <br /> 7yALTHORIZED SIQ�A4W AND TITLE <br /> *kkxkRkxRRlrt'RR #R#Rkf�RR �'Rtfxk##kkkxkkAR#Mkkk#1( #xRkk*k**kkxkkkkk*****kkR*k#R R>�fR#k#RRRRxRx <br /> En 23 a40 "11r4K ' , <br /> MAILING fN�Sf�tUC�TI0NS7 , iWHALF AND.SPLC*;'_ AFFIX PROPER POSTAGE, <br /> iv` t r"2.n�sh}13 :✓ TA.t, .r <br /> SAN--JO�iQUIN LOILTH DISTRICT <br /> P 4 — <br /> Alti7td$y UNDCF2Qt0UN�' TANK PROGRAM <br /> STCX?(TON, CA 95262' <br /> /`—`•.y .y.x'91 F_ -' \ti Y.,ry�� <br />