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tt Rf ff RRf Rffflfff <br />CTION 1 ------ <br />w w.rvwo"Ns"ffsl� <br />fixed With San <br />Identifoaquin Local iication 1th <br />n�abe strlctle lYat*oat mess <br />a uin The Tr&=Irq �t viii 400MV NW each tank <br />4 Local Health District within 30 days of acceptancen9 f the is to be returned to San <br />cycling facility. �g holder of t_ �_it With n of the <br />by disposal or <br />murine that rw�� r__ _ <br />CILITY NAW: <br />CILITY ADDRESS: <br />VK ID 139--Z( 67_ <br />ttlRRRRRRfRtlilRttfff!lfRff*ff=lZ;ffltlf4XRtfttt**ftttffifltttRtt4lt;tlftRtt*f;RRf**RRftxf <br />'CION - 2 - To be filled out by tank removal contractor: <br />'�k Removal Contractor <br />iress <br />lephone <br />tRRRRRR <br />`TION 3 <br />--- -, — —�Lur -aecc/ontaminating tank»: <br />k Decontamination" Contractor: AK � T / ,- <br />iress : <br />horize_ r«��„acave of contractor certifies b s1 1 <br />o aminated in an approvednner as may Y gn ng below <br />Y be regulated by Depart <br />!/✓ <br />the tank has been <br />of Health. gavuv, <br />,rI <br />Rf fff( Tofftffftfffftlftfftflftxfltkf AM TITLE <br />ZIttf*ftfffslk;ffffftffffffffffffffffff <br />ON - To be filled out and signed by an authorized represnetative of the treatment, <br />rage, or disposal facility accepting tank. <br />-illty Name 7.64e ,l X, <br />iress: -D YD, Al <br />.e Tank Received: <br />J <br />Zip: Z <br />25o/ <br />Aill' MIZED 3I u TUE <br />•RRt Rff R1Rtfflf!!!fltf!!f!!tflffftftiff!fffffffff►tfrftf•tfttfftltrfftfftfftftfffffffRtFtf <br />23 019 12/88 <br />LING INSTRUCTIONS: F= IN HALF AND STAPLE. <br />AFFIX PRW= <br />8AN JOAGUIN Local. WALTH DISTRICT <br />ATT”: UNDERGIROIND TANK PROGM <br />P• a• BOX 2009 MAR 10 1989 <br />(STOW t CA 95202 ENViRUrj(,AENTAL HEALTH <br />PERMIT / SERVICES <br />