Laserfiche WebLink
FACILITY NAM: California A=onia Co, ���yR�AiI I <br /> FACILITY ACOE?ESS: 22CI_ 1�i. Washinztor Stockton <br /> TAM ID # Unknotm <br /> [ 'ID TAMC DISPCSITION ZRa�CXING RSD <br /> This form is to be returned tQ San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facili <br /> with number noted ty. The holder of the permit <br /> above is resportsible for ensuring that this forum is completed and <br /> returned. <br /> To be filled out by tank removal contractor: <br /> Tar: -�semoval Contractor: North ^aI Cons rac' i•�n <br /> Address: P. Box <br /> '8 <br /> Phone # x:65-561,s6 <br /> Stock o,: Ca. Zip 95201 <br /> Date Tanks Removed <br /> No, of Tanks��_ <br /> SEMON 2 - To be f i l led out by contractor "decontaminating tank(,$)": <br /> Tank "Decontamination" contractor <br /> Address . Phone# <br /> Zip . <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated In an approved mariner as may be regulated by <br /> Department of Health Services. <br /> SIGNAILRE AND TITLE <br /> WrICIN 3 - To be filled out and signed by an authorized representative of the <br /> zeatment, storage, or disposal facility accepting tank(s). <br /> Facility Name <br /> Address <br /> Phone# <br /> Date Tanks Received Zip <br /> No. of Tanks <br /> ALAMFUZED SIGNATURE aNn TI TLE <br /> MING INS RULMCNS: Fold in half and staple. Affix proper postai. <br /> 1i N XX WP\T AC,SHT.LET <br />