REMOVAL REMOVAL 1989 - Laserfiche WebLink

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SALMI .70A*jl1V LOCALI Fi�T.r.� DI S PRI C'1' UNDERGROUND TANK DISPOSITION TRACLING RDODRD *x***zzz*xzz**zzz*zz**xx*z*zxzz*xx*z*zzzxx*xzzzzxxxzxxxzxxxzxxx*zz*z***zzz*****z*z***xz*x** SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet Is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the Mimit with number noted below la regDonsibje for ensuring that this form i``s uwlete and r=*_;,rnwt, FACILITY NAME: FACILITY ADDRESS: R `� a� �DVTI� �C �`7 y v �S A'I�'al\J to C/53a TANK ID N39- **xx*xxx*z**xxz*zx*z**xxxxzzx**zz*fiz**x*z**xzzzz***zzz**x*x**zxxzxxzx*zx****zx*x***z*x**x** SECTION - 2 - To be filled out by tank removal contractor: Tank Removal Contractor:._��r::,pnC_p Address: It3L �r.�, �T�� McU1�-��0 A Zip: Phone#: Telephone: ( �0 ) 5 N- CI�5 3 Date Tank Removed:_ SECTION 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: p Address: �� W, ��vTr�\'c �n /`alDksT-� Zip: 7,!57�;l Phone k: ?yri- yG Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE SECTION 9 - To be filled out arca signed by an authorized represnetative of the treatment, storage, or disposal facility accepting tank. Facility Name SZt��p Address: y.3\ Zip: Phone#: BOJ- S y9Jr 2 Date Tank Received: AUTHORIZED SIGNATURE AND TITLE EH 13 049 11/88 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. SAN JOAQU/N LOCAL HEALTH DISTRICT ATT#: UNDERGROUND TANK PROGRAM P. O. BOX 2009 STOCKTON, CA 95202