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L1:4'�a FF'1:11ELniI tt-l_DI i_iihJEU_ IVE <br /> MAY 15 1o�!1 <br /> ENVIRONMENTAL HEALTH <br /> O.AN 70RQY.I7l xV Iv.aaz, <br /> MDERG' an TANK DISPOSITION 'i4tACKIN(3 R§1RD <br /> !4**W******w**w***WWtyw*R****w*Yt**WWflw**w*******WW***w*Rr****w*WwWKw*********W**********W**** <br /> SFX."!'ION 1 - The Ban Joaquin Local Health District's Tzacking Sheet•, will accompany each tank <br /> affixed with its site identification numt)--r. , "he Tracking Sheet is to be returned to San <br /> Joaquin Local Health District: within 30 days of acGeptxnce of the tank by disposal oz <br /> recycling facility. hot tar oP�permithtly �314x1ow j rP,FQltsible for_ <br /> gAffi,I�S.�Iq, tha{s h}tis f.�m_=o�,.�o of ed_a1x] xe_t�.�S� <br /> FACILITY NAHE: i <br /> FACILITY ADDRESS: 2'i5 Sr•n ts. Lv'g .� St,x k on}�� ` <br /> TANK ID 139w <br /> "WrION . 2 - To be filled out by tank removal Contractor: <br /> Tank Removal Contractor: <br /> Address: C. Box 9 Hickr at (� �3 _ �� w _ _ _Zip: _2L323 <br /> Telephoner34 � Date Tank Removed. <br /> SECTION 3 -To be filled out by contractor ttdecontamihating tank": <br /> Tank Deaontaminationt' Contractor: <br /> Address: <br /> r __PhoneN-i <br /> Authorized tepresentative of contractor certifies by signing below thilt the tank has been <br /> decontaminated in an approved manner as may be regulated by Departntent of Health Services. <br /> SIGNA7** kDTITLr <br /> *R*** <br /> SECTION 4 - Tn-b-e filled out and signed an authorized represnetative of the treatment, <br /> storage, or dis sal faah�` J�7 <br /> XFacility Name 1„1„nt la�Yrs It tt tl< �•y�_ <br /> Address., _^�4�1 -25 9th Stre hktd c 953 i _ �Zil,: 05351 <br /> --•— ..� Phone R t <br /> Date Tank Received; <br /> Al Hopi SI(;HA7teB AND <br /> *Ww7t lr fr**wW1C*7kw**********W**k***WW**w*WWw*7fWw Nw w*Ww*Wtk**WwR**W*:k*w WWW w!�*WWWW***WW***w*W WWwW* <br /> PH 23 049 12/89 <br /> 14AILING INSTRUCTIONS: rOI,D IN NALI± A14D STAPLr, ArpIX pRopF12 F031'AG>., <br /> SAN JOAQUIN LOCAL HEALT!{ DIS'litIC], <br /> ATIN: UNDGR(s`ROUND TANK PROMS AM <br /> P, O. BOX 2009 <br /> STOCKTQNf CA 95202 <br />