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v ' <br /> AR <br /> OC. L r,, <br /> .� <br /> �;' UNDFRCItOUND TANK DISPOSITION TPJ"ING RECORD PER M-.T/SEttViCELS <br /> JCTICH 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> Fixed with itssite identification number." The .Tracking Sheet: is to .be returned to San <br /> laquin Local Health District within 30:rdayzs of acceptance of the tank by disposal or .., <br /> -cycling facility.`-'- Tbg holder, of the Dermit wtth•number noted belov' is LQ,"nsible for <br /> �jurina�hat thls ,foriq is completed and returned: Y <br /> .CI41TY NAME. Collegeville4Market Cafe <br /> rj i4'�;,•" i ,z . yf. �.- 4 e7 <Y.. Y1 3 j `= �s, F:�_"'. •'"`7 <br /> CiLITY- ADOl2ESS:' 3521 E.�.Mariposa :Road <br /> tt•• �` ._� l,r�� 5'"�•.� +..* ,'W�t„1'+'O`'lc�� �iY,.s \.,rsA �tai. K i,.%} T + "s^' 'd •tj <br /> '•D 8•�9'�. Z.L �+�x„, .,#.Y �xJ - + .7 <br /> r�tR <br /> r <br /> (.'TION ;-w;(2 - To be filled...out iby tank removal -contractor: <br /> ,nk Removal Contractor: A=A.-ATank°:removal and Demos <br /> idxess: 4900 N �yHWY f99 `#206 Stockton, CA. Zip; 95212 <br /> Phone#: •. 9�1_FR1n <br /> Date Tank Removed: :` <br /> .RtRRAR111RsltiRtRttt*t.Rt###RR**t##stt,!###t#*#*tRtt*!*##!##RttttR*ttttt***tittR�t*ttttttRttt <br /> );TION 3. -To be filled• out,"by'contraetor,:"decontaminating tank": <br /> ink Decontamination" Contractor: Same . <br /> Ore 9: Zip: <br /> Phone#: <br /> ithorized"•representative of contractor certifies..by signing below that 'the tank has been <br /> :contaaii'wted,in an approved manner as may be regulated,by Department of Health Services. <br /> W. <br /> SIGNMME AND TITLE <br /> tAtRR/#!##*ARlt#•!#ttlt#1t]t'.l#k."3�E'i'�'$!l"�#'XA#S•w##�f#'i#''.t.7�".'w7il:ti#ft*X###w##w`S##w##*2xfi�Ilefl.�'R#Sf$#t##tt#iCA <br /> =ION 4 - To Ge filled out and `signed ,� an authorized represnetative of the treatment, <br /> _orage:, or disposal facilit a ti <br /> P. �9 • <br /> ecl l i ty Name <br /> #dress: .� . Q ��' -. D• _ ZiN: .�-� . <br /> =` Phone#: - FD <br /> iter Tank Received' 9, y .l <br /> Ytpre <br /> AWMORIZED .SICNATURE AND TITLE <br /> �ssssss##t#sss#s##sssssitsss#sss#s#ft*##s*###s#t####t#�##x#tt#*#*tt#t#**#t*t##*tx*#tRttttt7tR <br /> N 23 049 12/88 <br /> AILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. - ATFIX PROPER POSTAGE. <br /> SAM-JOAQUIN LOCAL HEALTH DISTRICP <br /> ATTN: UNDMCROUND VA :K PMW,4m <br /> P. 0. BOX 2009 <br /> STOCXTZIN, CA. 55202 •• r1 r . <br />