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2 J(DPQr.;V T OL IIF�ALTH � gTjFLICT <br /> UNrERCR0U11D TANK DISFOSITION TRACK114C REOORD <br /> !RRlxR#xRRxxxRRxrx!lRRRRdRARxlxxxlRRRRxRRxRARf:RRRxRxR!!RR#RRlRRRRx*RR*RxxRRR!*!RR*x!*Rx <br /> The San Joaquin I,xaa. Health ')f'"rict"s Tracking Shen will a <br /> affixed vith its site Identification number. <br /> Joaquin Local Health District within 30 da The Trackdng 3hret is to °COmPanY each tank <br /> recycling facility. days of acceptance of returned to San <br /> cna,rl , �h91s� •. of hs the tank disposal•>_»53,,,.s_Ylth n �' ar <br /> --�-=nO..� his fpm fs ale___ ted and��:_ -D2hrd below i+ reQaona�hi c <br /> FACILIT7C NAPE: ; t'iC �- <br /> FACILITY <br /> ADDRESS: c <br /> �SZs! Now�I _ --koa_,>iv1k 4- <br /> TANK ID <br /> !#*l*Rx*R#!llxxxxRllxxxx#x!!#RX##x!RlRRRxxx/RxN*t xR RRxRlx*R*RxR*R R�x X:x;�*x!! <br /> S1#Mw - 2 LSC Dod / 8673 <br /> - To be filied out by tank removal cnnt.ractor: <br /> Tank Removal �mtzactor• Tj+vIC P <br /> Address f—__--------------- <br /> Telephone: <br /> *RRRR!*RR!*R*RRRRX!!R*R*#x!!R#RRRRRxR!*xIDaRR*lRTank <br /> *1[R*moed <br /> RkR*R!R!!!R!x!*!R*!!xR*Rig#!*R4!#?i; <br /> SaCTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ti; <br /> y Nae ,a <br /> Address: r �A• A_ .�Rt+�crrc <br /> kZ Cwt—_zl s aYo <br /> Authorized representative of contractor c•�rtif.ies by sign! <br /> decontaminated in an approved manner as may be regulated bolow that the tank has been <br /> by Department of Health Services. <br /> *#R!R*R#*RRRlR*!R!RlRR.IxR•RXR#xRR*xRRlR�xRlR�kER�RD**RR-�-Rx�RxRxRRk!!xlRIRRRRR##RRxRRRR#RlxRlt <br /> $WrION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> utorage, or disposal facility accepting tank , <br /> r"•ac:ili y frameTrc-,. �Rr?JUf."" r <br /> 112 J un cni c <br /> RANCHO CCRDpyA CAA q`o7g2----- ---- — <br /> —__�. <br /> Yin: <br /> Phone#: _- <br /> Date Tank <br /> RR*lRRRRRRlRx##!*!RX lRR!!xR*R*RRRR#!RM/ GNATURE AND TITLE "_.--•-- <br /> N,9I 23 049 12/89 xRRIRRRxR!lRxRlRRRRRlR#xRR*R#!!#**R*RRR!*RXR*x!R <br /> 141dI1.INC IN371tL�L'iIOP'S: FOLD IN HALF AND STAPLE, AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANX PROMM <br /> P, 0. BOX 2009 <br /> STOUCTON, CA 95202 <br />