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FACILITY Wz: <br /> FACILITY AMTMS: -IZ, J. 11-, <br /> TANK ID 1 Y <br /> UNDERORO[INO TAW DIS POSITIQrf 7RUXING RSD <br /> This fora is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptanceof tank(s) by disposal, or refiling facility. <br /> with number Hated T� balder of the permit <br /> above is responsible for ensuring that t dz form is completed and <br /> returned. <br /> To be filled out S7C.T ON 1 - <br /> by tank reaawal contractor: <br /> Tank Removal Contractor: <br /> Address: .'%; f,T /' •--.Phone 1 <br /> Lr� �n�p <br /> _42-.4n��n I%, Zip �5��� <br /> Date TW*s Removed F <br /> NO. of Tanks __ <br /> SOMON 2 - To be filled out by contractor '°decontaminating tank(s)Ii's' <br /> Tank "Decontamination" Contractor m:5!<�V,; <br /> Address 3I3 Phone! r - 660 <br /> Zip q,5',;14S _ <br /> # Authorized representative of contractor certifies by signing below that tank(s) <br /> &w(have) been decontaminated in an approved manner as may be regulated by <br /> Depax Of lth orvices. <br /> / <br /> SI GNATLRE AND TITLE <br /> SEMON 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name s <br /> Address ZS ' a Phiu�e��23 ?a,�8 <br /> -f 7 d c,d zip 7 <br /> Date Tankeceived u No. of Tanks <br /> AilnmzED =N LIRE AND TITLE <br /> s HAILIHU INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX W \TRAC;W.LST <br />