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uxruetutttttttiftttttteep•efeeeeeeHee�efee*1 I I <br /> IM Rome <br /> - The San Joaguln Local Health District$* `�eletaaeNeMreetiet <br /> Axed with its site Identification number, �y hac#i� �R will �OMOMamy ee A tank <br /> .,lain Local Health District within 30 days of he T n9 �t is to be returned to San <br /> cwling facility. Th.. huldPr o ptancro of the tank by disposal or <br /> !urirls that this forty 1� It <br /> m1P* <br /> J _ <br /> CILITY NA,%E: <br /> 'lLITY ADDRESS: <br /> C <br /> r �� - <br /> YK ID 039- <br /> ---------- <br /> 11011 <br /> 39-xxxxxxxttt11011 - 2 - To be filled out by tank removal contractor: <br /> ,1k Removal Contractor: r c - <br /> c i� t <br /> tress: _ � <br /> r c s <br /> iephoneLI_) 5 �� <br /> xxxxxttttttttttttttttttttttttttptttt--Date <br /> te*$anti Removed: tttt3a�t:a=x=xa:xct:tx:txxxxx <br /> TION 3 -To be filled out by contractor "decontaminating tad:": <br /> A Decontaaination" Contractor: ///1 1 <br /> � G / r <br /> tress: / <br /> � 4 � <br /> O v <br /> Zip: f <br /> Phoney: % � _ <br /> -horized representative of contractor certifies by sl <br /> -ontaminated in an approved manner as ng below that the tank has been <br /> �Y be regulated <br /> by Department of health Services. <br /> ,TIQNaxxxxxttttttttt*:,►*,ettx**ttwRttaRt*tt�ita�tt�:�=t*�et=**trettttt*tet*t*ttxttttttxrxxtx* <br /> tags di 1 - be filled out and signed by an authorized represnetative of the treatment, <br /> rage, or disposal facility accepting tank. <br /> :ility Name <br /> iress: <br /> Zip: <br /> e Tank Received: <br /> SIGNAum Am <br /> xxxx•xtattrttttttttttttttaattfn ttx� �ett� ttaMs'!;E*t'*tt**ter*:tet*tt:ettttttxt,x <br /> 23 019 12180 <br /> LING INSMLX.TIONS: 1= IM Mein AM VMPLE A"IX PIIDpM POST11iZ. <br /> P. 0. BOX 2009 <br /> 37OCK"t CA 95207 <br />