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UNDERC,RCUND TWX DISPOSMON IVACKING RSCk'.) D <br />*******P********RR**it*X'**RR*6 6*******x***tw*A.*:a***** #" N<r*i*******PYA*%-**'k?'*i:R4: iamR*fe***AR* <br />SECTION 1 -- TPie San 3oagQir, Mealth Dlstr�ct's Txacklnq Sheet will accompany eacYj tank: <br />affixed with its :. itE identification nlxrber.^hv TCW-' !C.'q Mjeet is to k-_ r.eturne�d tG San <br />Joaquin Local Pealth District within .'•0 days of -Iccn p-Ptance of the taf-Lk by diaposal or <br />recycling facility. <br />FACILITY NAME:_ <br />FACILIT•i ADDRESS: <br />TA14K ID <br />A*#Sk Y.#r_' *ns Rha. A A*Wx rr*R 4:a*Rk'4."J"A*0A;*t A*%AAA*#»*ItRW*A*A***v *IV ***RTx <br />SEX'i'ION -• 2 - To be 9,1Iled out by tci.k rernoval contractors <br />Tank Removal Contractor <br />Address: <br />Zip: <br />02 7QM <br />Telephone: ()_ lkate Tank Refgoved: !V �.NNxNTA HFAir,__ <br />*R**#*R#Xx�'.#RR#**X*A xnX RrA#RA; it*xxx**'#R#*RRA:R*h•t.*kR4*ser.aXtffRf!1-R*�iRA#Rt##A!:RRX1iR*#Rx *XirA %*'?tA <br />5ECr1 W 3 -To be fillet' out by •centr.,,cto. "decontauiinatinq <br />Tank becontairAnation" t Intra :t os : <br />Address: <br />Zip: _ <br />authorized reprP36ntative uf contra -tor certifieF, by Bien', -j, !k3'1. �'W' t?ieA'. t%e tarlk has iT32n <br />decontaminated in an appy. --weal morn:: aS WAy be reg•11atzd b_, nepartn,ent of f?ealth SErvif,'_S. <br />SICNA RJRN AND TITr.E _ <br />#*RRR***RXX*X*h***y%**xXxftkitRA*•*#.%#uy-hu*a hk k"R**.A* RY<fi*RA.dxt�lS**ri*Rf:hXhr.sRR*R%xx#'***+irxR*Ra'X <br />SrITIO!J 4 - To to filled •'Dut anrr,� Signed. by an .3`17:i:t7A-!2�^t) £�spr8snc-'ceiti'le Gr: t,;i^@ traat,ient, <br />storage, or disposal f_vcLli-y accepting tar.:. <br />Facility_Name <br />Address: 3525 <br />Wte Tank Received:_ <br />F!7CfdhTU4'sE yhrib TITZ2 <br />*****kR* 'Y*%9:#,%?;RXkRR**der„�:>xr.*vstkr*#rt$#RxAt#RR xf RX*kxRik#**R#RA#*#* <br />Ph 23 049 12188 <br />IWLiNG INS TRLCIFTONS: : <i .0 Ii., HALF A.N7 S'tAPI.E, OSTAtE. <br />SM' JONQUM LOCAL, HR'7L.f:H DISNIC-1 <br />A"1114 : L'NDORGOUND TRNK PROMM <br />P. 4. WX 2009 <br />SjV_X'MNj CA 95202 <br />