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ISN DERGR cwt U TMX U I S PO S 1 T I ON TRkCKZNG RFG.� <br /> **kk*kk*xxx*xxxk****Mxxxx*RxR � RxiRR1RrRh1RRRK*x*RR xxxxxxxx*kxkkw�r�lx�re��cwxw*�**�iee�r4r�xN <br /> Yobs 1 - The San J.oaquln Loral HeaItn DI5crictIa Tr ckIng Sheet will accompany *aah'tank <br /> ltiXod with it* Site ldenttflcatLon nwrDer The Tra king Sheet to to be returrwed� hp;Jwtf <br /> Joaquin Local Health District within 10 days ut accept nce of the tank by dispoaax�'o�C !I <br />'*cycling facility, J' <br /> Ij <br />'ACiLITY NW.., CLARK WELL, INC . :! <br />'ACYLYTY ADDMS; 2Q2q EAST CHARTER WAY, STOCKTON, CA 95205 <br />'AM ID 039-_/CS3. - 2 <br /> Iwwx,r�l*w rrxkw*�** kkk*k*xwx*xRRtFtxRi *RixRRxxRx ■ *RRx**xx*x***x*xx***k*xw*I;*** <br /> 1=710H - 2 - To be filled out r-)y Cank cQmova i k:ontractor <br /> Wank Removal Contractor : IALWN �NERGY <br />�dreS � M. Box 1257 ZIP1 95201 <br /> Phone#; �I <br /> vlephone; (ZQ2 ? 53 7108 _ Date Tank Removed ; Z G A4 GIS 1 4 <br /> rrtrrK*w�l�lwkk**wkkw**kkk�**k*�xaRKxx�Rxxx*,�xxxx�xx*,r***k*xxrryrx�l*�*ww���rww�k�#e�w�N��,��.�**il*1�N!R <br />=ON 3 -To be filled out by contractor "decontaminating tank" : I� <br /> FALCON ENERGY <br /> Ink DeconCamination" Cvntraccor ; <br /> 4drow P.O. Mx 125Z it <br /> Zip <br /> ) ' <br /> honel ; <br />�uthorized representative of contractor certifies by signing below that the tank' h"'�b*an <br /> I*vQntaminated In an apoved manner as may be regulatfjd by Department of lieal'rh:SY,1.Q�i►il <br /> JAMES J. HOBLITZELL, V.P. & ENVIRONMENTAL MANAGER <br /> SIONATVU AND TITi, - ! <br /> r�t+arr**rrwwwwk*kkktK kkxxx***xkwxxxx*x**xx**xxx****x *xkxxk****xYflY*yt7llt*1r**kiM w ** ��wwK <br /> SW rICH 4 -' To be tllkvd oue and 6117"d by an author 1 od reproonstattvi 99 ` <br /> 0099499( OC d1opos41 tidlllty accepting tank , <br /> Woof; 424 TEGNER kA.DrHRL 0C <br /> K, CAL I 50RN 1A <br /> � I� <br /> hono 1 ii.�� M <br /> Dote Tank Rece 1 ved Z s Al q <br />�wV�1lA 1 Hwy—r.� ........���� - ,- lr•I � .'a: /: . !� <br /> A11MOR I ZED S IONATVRE XND TITL,E <br /> rr�rrxrw rsrrxwxK�k*ilk*kxx�NxaxxxxxxxorAxxIIxtxxxxxxxxltxxxkk kkkliwl�kwiCk"rrrrrwwrrl�wwwwkww'**N ��Rw N` k <br /> air33 �a�9 izie� LI <br /> MAYLlj Q INSTRUC'l'IQNS I FOLD IN HALF AMD STIWLC - i X PROPER POST11GItrr <br /> 5Ah JONQlN L.Q( 1 R(EAL,,TH DISTRICT <br /> A'1rM ; UNDM(t RGVND TANK PROGRAM <br /> DOX 2009 �!I <br /> STpCX'MN, CA 95202 I `.E <br />