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k-f HEAD"IC'�Lnl 3� � <br /> ; <br /> SAN1(1r QUIN B)UNTY <br /> 1061 KHANNA hl.l?.,DLI'H. ; <br /> -7-He0th UfFiCer JUN 2 3 19909 (16 <br /> �. .' <br /> 01—]oast-.Hazelton Avenue) Stockton, Cnlifc,r:, a c)5:-(?1 <br /> X468=3400 ENVIRONMENTAL HEALTH <br /> NDERGROUND TANK DISPOSITION '['RACKING I:r?(-c)KRM SERVICES <br /> 4 ,p1 — <br /> q fit•fi#a�' #�►Ytfi####fi#fitlr#'#'##t###t#######t#########11####4•k#itkkYtkkt:kktkk>+•'isx k>1:t ttt t.t kt#tf###########te# i� <br /> }' SE4 IONl ;: Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. Tie <br /> Tricking Soh et is to be returned to Public:health Service, within 30 days of ncccptance. Of the tank by the disposal or recycling !' <br /> fat-li!N Th •permit holder- i r <br /> q. or. is for cnswin„ that this form is completed and returned. <br /> f� Aft/ L <br /> - (,-' IU,-DC.CCriplill l: !_�.. �ciL !l(1:,!f�:!t•. �,: i C ��5 <br /> k'/t Pt*.*'%'t t+.-#'k k++I I+ <br /> SI t J-10'N 21.- To be filial Out by tank rcrnOval contractor: <br /> Removal Contractor: <br /> city: Zip: <br /> D•rtcI'- anl. Removed: <br /> -- � , <br /> ovc(1' <br /> --*-'trt'Yi:t/fT ttt tr Yk l/kl:#tk>>##1 tt Rf t>ktltk Rt##ttt <br /> Sz:C'I I( N .Ito he filled out by Cc)trtl£iCtOr ylecontaminatin« tank": E t, <br /> Tank Decontamination Contractor: �_�,1,��i•� `��"� tee^,,..".,. ' -- --,`�c,' __��. �'�•= �-.Y 1 �". Fit' �. <br /> c+drestif <br /> : �� --_ 4 �. '� t—C � C.il <br /> 1Zip: <br /> .•� <br /> tt r Phone '# ` • ) _ tt* 1 �'�.` _ _— <br /> III <br /> tP{ ^fi s <br /> Vithorized representative of contractor c•crtified by signing belctw that the tank. bas been decontaminated in in approved <br /> i , .manncr as required by the State Department of I-Icalth Services. <br /> #� <br /> .•,tore Il+t. f:r �,'t TiIIC: /fr �"r r/►, r / I <br /> s f r t •t#s####t#t#####t#######R}a k##:/#!i 4####i#:Y:k#####'##########+:t+#+'Y'k t R###*###i'F t##'k#i####fi f i#}#t####t#t•+ j <br /> cz i I0 4 - To be signed and dated by an authorizer) representati�e Of the troMment, storage, or disposal facility f, <br /> accepting lank and/or piping. <br /> Martie: <br /> a <br /> t-;!, p sa: tr.'�� ^ -,. j�41 <br /> �J,: City: C_.'_ 7.ip 'I5 t. i. <br /> J 1 r <br /> ' f`;li'_• .7•nnk F;cctia'e �'2z` / Z <br /> ---------- --Cry ----- ...----------------_ ____ ._..._ .. .._�--- � --- -- <br />,�� �'.Sidnattrre: . <br /> I , <br /> #+..r't k I+it'k:k t t k 1 R Y k t•k t t t l#'_i t'Y k t t t l♦Y t#f t t i t f f Y f t i. <br /> tt <br /> Page to <br /> P. 23 049 (Rev 2/8/91) up l <br /> A Division of San Joaquin County Firald, <br /> t <br />