Laserfiche WebLink
Loy <br /> FACILITY NAME: �H�fDc) /'/hS/rr��irnl <br /> FACILITY ADDRESS:_-LU 15 AILL 4TANK ID / .3% JL_3-D1 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form Is completed and <br /> returned. <br /> x x * * x * z x x x * z x x z x x SECTICN 1 - <br /> To be filled out by tank reaoval contractor: <br /> - Tank Removal Contractor: RART00 CONITRUCTION <br /> zy1'7 Address: 22580 S . MOFFAT RD . <br /> Phone N 599-2176 <br /> Ripon , Ca zip 95366 <br /> Date Tanks Removed 12- 13-88 No. of Tanks 2 <br /> SSMCN 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor Sim Th o"e <br /> Address �".J,� PhoneW al�9� �(��-To�7j- <br /> zip - <br /> zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved 11 manner as may be regulated by <br /> Department of Health Services <br /> SICNA AND/TITLE <br /> x <br /> SECTION 3 - To be filled o�and signed by/an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name P;C4 i/ A,'c <br /> Address L' 13ca is r} j Q PhoneN �z-- <br /> ` — p �fv C/or Zip_ <br /> Dae nks �e i 2 j S- No. of Tanks_/ <br /> A ZED SIGNATURE AND TITLE <br /> NAILING INSTRUMCNS: Fold in half and staple. Affix proper postage. <br /> EH N 70( WP\TRACSHT.LET <br /> D �15� �� o <br /> Q <br /> JA N 11 1989 <br /> fiVVOONNIEN7AC HEALTH <br />