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!lRttfRt!llfHffflftf Hlfffiittfiitf°*Mfff°!f � r I) I +' � I' •; , '�� ��}} <br />CTION 1 -The San Joaquin I1oos1 Health Districts* !calf <br />fixed with its site Identification traber. The Ttadtl�nq �t will aOOCspmy each tank <br />uyuln Local Health District within 30 days of aooe �1Nt 1s to be returned to Ban <br />cycling facility. The holds. pt"W8 °f the tank by disposal or <br />.. of the r rm11- ...i4u <br />CILITY NAME: <br />'ILITY <br />JK ID 139- b _ <br />tt#**ttilRat#R#!!t!##1!lR1R#!RR!##fRf!!RR#R####1tRlf*f!!f!#R/ft1tRR#R#t**R1R#R*RRR**Ytt** <br />'TION - 2 - To be filled out by tank removal contractor: <br />-Lk Removal Contractor: 41, // / / Z <br />cress: V_ L A/ <br />�f Zipc:� <br />Phone#: _!L.L S� <br />Lephone:Date <br />S!t!t!!!Y!f!##!#!#t#!!#Rt!#!!!!# !ltfflank Removed: -_2 <br />tR#2*!#t#!Y!t <br />'TION 3 -To be filled out by contractor "decontaninating tank": <br />A Decontamination" contractor: <br />cress: <br />ip: <br />-%orized representative Of contractor <br />:ontamininated in an approved Wanner as certifies by signing below that the tank has been <br />�#t#t#t#RRt#fttttttt!!lttitRRtttt!!Rtlt!!#### �tlR!lRtlR!!!!#tR#t*lttR###!t*t!#!!t• -,— #R� #x## <br />'!TION 4- To be filled out and signed by an authorized represnetative of the treatment, <br />,rage, or disposal faacility accepting tank. <br />alit Name____L`Gae�.� d <br />tress: K 71 <br />Zip: <br />Phone#: <br />.e Tank Received: Y <br />1tR <br />lf1Rltf!!!!f!i!t!!!t!litR!!!!!!!#tRtf Rif/tf�fifRl <br />23 049 12 <br />z3 �9 188 tut <br />LING INSIRUL'iI0NS: FOLD IN HALF AND STAPLE. AFFIX PROM POST v1 <br />1989 <br />SAN J0AO11IN IACJ1[. FFAL14i DISTRICT MAR I V <br />ATTN: UNDERCIRGUND TANK <br />PROGRAM EN <br />P• O. BOX 2009 PHEALTH <br />PERMIT <br />STOCKTON, G 95202 <br />