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y <br /> SA1�P .7 VaN L�CJ� .TH <br /> � TAW DISPOSITICH TRAcXjUG <br /> affixed <br /> kd 1 The San Joaquin Local t{eelth District's Tracking Sheet will accompen ea <br /> affixed vith its site Identification number. #*� <br /> Joaquin Local Health District vithin 30 days of acceptance of tt:a Y rani <br /> The Tracking Suet is to be returned to San <br /> recycling Facility, <br /> tA, tank or <br /> FACILITY M&M; <br /> FACILITY ADDRESS. <br /> TANK ID 139- e!/y <br /> $f1R11'ff#f#ffffff#R #� ffk�tf#ff#Y�t*# <br /> SECTION - 2 4 To ba filled out by kaNc rEAc3vel #*'�*�efffff##�ff�t#afar*ff*ffffffxx <br /> Contractor: <br /> Ta* Removal Contractor: S�Ncco <br /> 9 <br /> 1lddres.: "3 uJ• C- <br /> ES�'O � <br /> zip; 2t� � <br /> Telephone (��� _ Phonef; <br /> [Dato Tank a*fia # ,TRea#f:ef###ff#�f*fefx: <br /> tRemovW; <br /> SMTIQV 3 -Tobe filled out by contractor <br /> "de, <br /> Ontaminat�ng tank": #Rf**'e*�*fYfx:sx*,r* <br /> Tank Decontaseir&tion"'Contractor: � <br /> Address: � T <br /> p �Zi l <br /> Authorized representative <br /> decontaminated in an aof contractor certifies by signing <br /> o manner as 9 below that the tank has been <br /> . Y be regulated by Deicrtment of 1ealth Services. <br /> k #Teff#ff#fR#*#ffuf#fRgreYtRRIeRxRB#fRff##xf�'#fxfsf'##r7atre#*TLU. #:ta####a#fes f '�- y�� <br /> 3IC�,CAT1� At�FD TL U. <br /> SECTION 4 - To be filled out and sS —�� <br /> storage, or die geed by an authorized ref#x#*ff#f:#�##f,r# <br /> poral facility accepting tank. presnetative of the treatment, <br /> Facility Name r►l <br /> Address: o S <br /> Date Tank Received: hone#: <br /> f t 23 049 121ffRRfgf**Rf��ffasff ��f�*�r���*f*J�*TRa <br /> -« <br /> Sit ?J 049 i?/8d ffAfffsef*ffft#f* f�rx� <br /> HAILING I11G`i'IOYS: <br /> --QLD-IH-H11L�'-AN,3 - _-- ----- ---------- <br /> SAN JOINLOG[, WALTH DIMICT + <br /> P 90X 2009 <br /> TSMC i ] <br /> SItiCCTCN4 CA 95202 <br />