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Mi�bfrT <br /> y TMW DISPOSITION ZRACiCIM <br /> L #st*# <br /> 5E7CTi0N 1 - The San Joaquin Local Health District'sTracking Sheet will accompany each tan, <br /> affixed with its alta identification number, The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by diaposal or <br /> recycling facility., 'I'X holder, of the oermlt with ="g ngtc,b:1Qy_ bs ZespQnsIbIC for <br /> -Ig cc 21CtCA and-returned. <br /> FACILITY NAIL: r=c�l�n1�k �U� •-_ _ _ _ _ _-_ _ <br /> FACILITY A.DDRFSS: 2!� <br /> xxx#>tD0 A�#f��rr��sfi��ft��e�#��x�x�t1�xirs�tir*itirtririr��irssx*#ttt�#xx*a.. <br /> - a filled out r val contract": <br /> SF�TICN - 2 T be 4by tank era <br /> Tank Removal Contractor:_ f2'n 2 <br /> Address: Zi <br /> e <br /> - <br /> Telephone: E293�. Tank Removed: <br /> s=ION 3 -To be filled out by contractor "decontaainating tank": <br /> Tank Decontamination" Contractor: --P"nN( -0-- - - - -- - - - <br /> Address; ) AL - <br /> Phoneli; X2-(4ID -2) <br /> iouthorlzed representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved mariner as may be regulated by Department of Stealth Services. <br /> BIWATLRE AND TITLE <br /> SECTION d - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility acxapting tank. q� <br /> Facility risme rcNcs.� �-.E, If1 - Y 'l��-�4L_S IClj= OA-;Q , Coe-�V— <br /> Address: A&L zip: 1 <br /> ' hom l: <br /> Date Tank Rece ivied: <br /> AVPFiORUM SIGNATLRE AND TITLE <br /> ��**ft#ftit�t7rtsxlt#it*it#s#ie##s#ss#a�:,r,e�ait��a�r*,�a�"*�r�at*�r*stxsa��r*�ft�,ta�rft��s##atsx*airs:ter:t**xxx <br /> lEff 23 049 12/88 <br /> WAILING INMUC TIONS: F= IN HUZ ZND STAPLE. AFFIX PROPER POSTAGE. <br /> ' SAN 3DA=N LOCAL HEALTH DIS RIM <br /> ATIW: LMMGROUND TANK PRQGR M <br /> P. Q. BOK 2403 <br /> STOCKIM,r CCa 95202 <br /> i � <br />