Laserfiche WebLink
ti+1 <br /> 10 <br /> 4b <br /> _ LLr 16 <br /> i�p <br /> 0 <br /> SAN JpAQUI N I-C7CL HAAT .TH L72 STRCNI V`CITTH <br /> JNMGNTAt HEAL <br /> PERMIT!SERVICES <br /> UNDERC;RaW TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The `[`racking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY WE: (f C) f2- o P C-I <br /> tA <br /> FACILITY ADDRESS: 4D � <br /> o v�J l-s C�=} <br /> TANK ID #39-- 1`14 - <br /> SECTIO! - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address; e121 I Kka 1_-g^"= Zip: <br /> C_A Phone#: r11 t. - 3 7 • 1►7 <br /> Telephone: ( G co ) 27 - 11 Date Tank Removed: Nave Er-- <br /> *al**atalt***al***at*******aC`kar*#it*it**at***Ytat*****�Fatic**�C*****at*********alit**iMat**at at at*at*t*at*****at**k** <br /> SECT'ION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: CN '^Je-y= 21 rv�. <br /> Address: Zip: <br /> Phone#:(Rj LZ I- Li-?-7 <br /> Authorized representative of contractor certifies by signing below t1�it the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> ******ak*******al****otic*******R****al****at*it at**at*ir4t*•kal******•kik****ir*it'kal**kit**ir*'kiC7l***ir****ie at*k <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name G`l2aa �sI�F-tE1.tiT <br /> Address: 11 ' ► 5 Sourr+ R1Q 6z Zip: <br /> pow + Phone#: qty 3S- <br /> Date Tank Received: <br /> AiJI'HORIZED SIGNATURE AND TITLE <br /> E!! 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLC. AFFIX PROPER POSTAGE. <br /> SAH JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TALK PROGRAM <br /> P. 0. BOX 2009 <br /> sTOGCTON, CA 95202 <br />