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w <br />eefteeoeR!!!ee 5 � <br />CTION 1 - The San Joaquin Local Hselth DistrICtse <br />!tacit <br />fixed with its site identification number. The Tracking <br />Uq4j6t will aooss#rw each tw* <br />aquin Local Health District within 30 days of aaae BArat is to be returned to Ban <br />cycling facility. Mg holder ptanos of the tank by disposal or <br />.. of the ner�fl- ...t��. <br />CILITY HAM: <br />CILITY <br />^UC ID <br />-CION - 2 - To be filled out by tank removal contractor: <br />Nc Removal contractor: <br />tress: <br />Zip:S_ D S <br />olone#: S <br />lephone:/Date Tank Removed: y <br />##;#*!!!!!*!!*!!!;####;##;###;!#!#; <br />'TION 3 -To be filled out by contractor "decontaminating tank": <br />* Decontamination" Contractor: <br />tress: <br />-horizea representative of contractor certifies by signing below that the tank has been <br />rontaminated in an approved mariner as may be regulated by Deparxpent o> HealfjPsar.,, .ems <br />�!►##!#s!!!;!!*ltee!**!!!!t!!!!!!*!!UAt#Iesia#AxOt!*!TLa!!!*!*!!t!*!;****tt!!*!*!*!!*!****;! <br />TION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting tank, <br />:ility Name_On�,_ <br />Iress: '17 ' ' ,N I ..l <br />zti Zip: <br />Phone#: <br />.e Tank Received: ! % <br />v <br />AMMIZED 91 <br />IND TITER <br />AMD -rTWJP <br />13 019 12188 <br />LING INSTRUCTIONS: FOLD IN HALF AM STAPLE. AFFIX PROM POST l� � a Y4f� <br />SAN JORMN LOCAL HULTH DISTRICT U <br />ATTN: u OUNNK D TAPROGRAH MAR 10 1989 <br />P. O. BOX 2009 <br />8700(TOiI, CA 95202 ENViROP.r,9ENTAL HEALTH <br />PERMIT / SERVICES <br />K <br />