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to r*�ft*retftNRRRRRRf ttffffffRR ���IIV' II `" i <br />CPIDN 1 - flffffffRRRffafflt <br />The San Joaquin Local Nfalth Dl8trictls ZtaaC�t+Rs <br />fixed with its site Identification number. Th* Tt+dtibqng �t will aOoom��y� trralc <br />cyuinrll Local Health District within 30 days of ecce 8lnet le to be returned to San <br />S,}iCrin�rtia4il.tY• The hot z o *►+ reit w�tA Ptancm of the tank by dlspoeal or <br />CILITY NAM: <br />21LITY ADDRESS: <br />X ID M39-- <br />tt!*ittat!*t!!RR!*t*tliRlRRR�tRRR*R**tt*t!tlRR*tRRRtRRttt*****RRRRRRtt*****t******* <br />'PION - 2 - To be filled Out by tank removal contractor: <br />Ik Removal Contractor:_ lv/i Tt/ /- <br />cress <br />lephone. _ <br />Rt•x***tt*t**tteRteR*ttRRRRRR***t*RRtRR�tfeTank Removed: _2**� <br />Rt* * *******tt**** <br />'PION 3 -To be filled out by contractor "decontaminating tank" <br />1k Decontamination" Contractor: /l/, . 2`11, / _ / -1 1 <br />cress <br />« a Zip: %S^ 5 <br />Phone/: 6' _ <br />-horized representative of contractor certifies by signing below that the tank has been <br />:Ontaminated 1n an approved Banner as ma be regulated by Department of Neth ServirP, <br />1' <br />�*********!t*itRRtttlRtttRRRRRRRRR*Rt RttltlfAiRD*t*1TclEtRR*RtRRtt***t***t**ttR*t*ttR*t**t** <br />TlON , or disposal h filled out and signed <br />by an authorized repreenetative of the treatment, <br />"ageposal facility accepting tank. <br />:ility Name_ ��>� / Z „I- . // <br />tress <br />-/i�,646-> /7J 11 rt <br />✓40,Zip: l <br />Phonet: <br />:e Tank Received • <br />o_ <br />.*trf**t*!!ttlRtR!!!ttlRRR***Rte !llttlR�R*Rt*qtr*Rt*RRt*R**R1tfRR*RRRRtR*R***t**tRRRR**R*tt*** <br />23 019 12188 <br />LING INSTRULTICKS: F Z IN HALF AND STApLE, <br />AFFIX P[aOPffit <br />SAN JOAMIN LOCAL HEALTH DIS"ICP <br />ATTN: IXDQR(;ROLND TANK pROQtAN <br />P• 0. BOX 2009 MAR 101989 <br />STOO(TON, G 95202 <br />ENVIRONMENTAL HEALTH <br />PERMIT I SERViGES <br />