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. _- .. — . v.c ar.,ci .a,- I ♦ -- Ln.Y 3555 lY=YS r nb <br /> -.e-��ac 544V'd t t G <br /> SAN JOAQUN COLIdTY MDUC HEALTH SERVICES <br /> E/'lmcwmEYPAL BxALTB i)fvmo Y <br /> LNDERGROC.N-D bTORAGE T.i.VK MWOE SON TRACSLVG RECORD <br /> ..e............a.....+_.....n.yvol..aa...+.a.....a.t:aa..f..Y.Y1P.......atTa.f ffllsiw.i.aaa.......... <br /> SECTION 1 - Puaiic geAltb Scrviem Esvtroamentai Kaalta 7iv san Tauk T-=Y g 53eet saUL acoz+pmp eae4 unit zfaed <br /> 'yid its rile idecdflcacice amber. The Tank Tmccmg She.s w be:r.>ar-m w Public Heaidi 5crvices Euytromoexai Heol:: <br /> Division within 30 days of acceptanee of the t k Sy LLe disposal or cswclirg facility. Tbo permit hoide. is-Isp=Ible'ur <br /> ensu mg :hat this forms compiered and reamed. <br /> FACIL=NAIM£:__ AJ1A <br /> /i <br /> FACiLl. ABDRESS--- 7.s� Z <br /> (h.' /may C� <br /> 1790 i31 Z9 _ <br /> TANK tD 439 -rtlda,�f1 TA.,�"&3FL£: oRE'✓T.CUS TANK CONTEXTS- <br /> .......... <br /> :NT=P7T5-a...........faiva Y.....vwar.o.r...a..............u...............................-.............. <br /> 33ECTSON 2 -To he :filled o4c by taoit.removal eoavaaor: <br /> Tack Removai Cottrracnor: ET ✓'r- { -T�� <br /> Acdrm d �l(7 CC �+'yu"" rrJt'_ v <br /> r dry: <br /> ?tone 3: i+Z 45 ) �'S � �� ,� Dam T_,k I=wved:-- ---- -- - <br /> M.Mf V.Y..V....w.Yv......a..wu...a.a.....iY.Y.A.....MYYw.M...........uaa.a.w........buYf i..a.u.a <br /> SECI•ION 3 -To be 811 nus by contratsor 4deeoactminn�UMVk <br /> T3 ak Decoutmniairoo Cocaaeror: <br /> .addm": �c f�V� 1-- Ctv: <br /> Phone f: r-% e �L - `�'f� /'0 <br /> Autbr.Zed!epvzeamave of `=arum heron bat x tlnk-'Zsbe= !F--om=mna=s m Apruled <br /> mane:ss :eauired by Cai E?A- <br /> name: `T:da: Siantre: Date -- <br /> m.a:..a..w.Y.rww..a....u..r..oa.waaa.a.a.aaaaa..YaaY..u.r rwrurvrwe,.r.roaaY...Y.waww. <br /> SECTSOPI s - To be signed gad dated by w aurbortzei representutye M the •^ent, stars, .tr J3slwws+t 'a[44 <br /> xe:ye`in,g,ank mcAdlcr gigot;. <br /> Pxi3iry Name: <br /> Adams: 't �a�� C,�/. Cary: rr� cw.r .� Z!+: <br /> Phone A: <br /> Date Tanis Reeeised: <br /> Name: -tie: Date <br /> ................w........................a.......................y..._..........>_._..................... <br /> EH ;3 oa6 tResised 9111196) Page t0 <br />