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�3 u29t2 ultltR t/ffNRRt � R 11.1tl'..•_•.�...t,..2,�.r <br /> .CyV 1 <br /> The San Joaquinocal +f*fuRttf '• .. I! II,"•tip •k .. .::_ - <br /> tixtii with its slteentlPlaatlo I�ermtrict2a Tr <br /> 1,:in Local Ileal �16O deet Y111 fMtt <br /> "Y'Cling facility District within 30 days of heOTraclrinq A1elt !a to be r mw � taril; <br /> rl t Ptanoe o! the tatUr by disposal r° Ban <br /> 'ILITY NMSE; <br /> ILITY ADDRESS; �— 0 <br /> OK ID /39-��__ c <br /> �iittt2/!l404tt!!!tltf!!tt!!�!lttitlRtt4ttlttfRlltfl!!lRRfltttlt! <br /> 'I'ICN - 2 - To be flllr_d out by tank removal contractor: ttf*RtllRt:tttlttxx <br /> �k Removal <br /> Contxactor• = C, <br /> cress: 2 r <br /> O � �F <br /> Zip: �S <br /> Iephone: PhoneO; y��2C)GO <br /> . 1O 3 Rt!ltt ttt. 1tflt!®;tit!lltkkxxk!!RemovellttRltltlt!! <br /> Date Tank Removed:_ -� <br /> TION 3 -To be filled out by contractor <br /> "decontaminating tank,: 4t:ltt:tttl:ttR9:xxxx <br /> ,k Decontamination" contractor: <br /> horized ZIP: _2C/ <br /> representative of cants PhoneM: _ f�G <br /> ontami red in 'GPz actor certifies by signing ng below t he to <br /> gnI that t <br /> � -regulated by Depi3rtment of Health nk Sezvicee1, <br /> �t3Rtttlttfotit!!!lRttltttttttt**Rt*RtRtltlxt!!!tfl tff!lttttttlRltltlR4ttttlt! <br /> TION 1 8I�1S1StE AND TITLE <br /> - To be filled out <br /> ,rage, or disposal far llit snd signed by an authorized re lxRR***!!!x <br /> _/ Y ti tank• preanetative of the treatments <br /> :i11ty Name ') <br /> tress: <br /> e Tank Received: Phonelf: <br /> SIGNA <br /> 23x049!!!lttttllttRttttttttflttRtlt=t�!ft Rt!l1t1lRttftltt <br /> 23 019 12/dt TITLE TI?IE <br /> !ItiG INTMUC 1I X20 81'APIE. ya. <br /> ON3: F� IN 1171I.R ttRltRtltlt:2222 <br /> AFFIX p10PUR <br /> X2111; I Olt1DW AD pROM� <br /> PIF 0. BOX 20090 <br /> SYOCM"s Eli 95202 <br />