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FACILITY la)DRF,.SS: _ <br /> TANK Io �c1 <br /> LXCMGRaa ND TAW D �MoisqjTT-ITLT�ACIf ING <br /> This form is to be returned to San Joaquin D <br /> a�eptance of <br /> Local Health District within 30 days of <br /> tank(s) ,by disposal � r�ycling facility.with number noted y The holder of the permit <br /> above is responsible for ensuring that this form is completed and <br /> returned. <br /> * * * * * 0, * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> TO be filled out by tank removal contractor: SECTIc" 1 - <br /> Tank Removal Contractor: <br /> Add-cess: <br /> a Phone � <br /> Zip <br /> Datf: Tanks Removed <br /> No. of Tanks_ <br /> -94MC lr 2 - To be fillod out ,� <br /> *� by contractor decon�inating tank(s)": <br /> Tank <br /> i7econtamination" Contractor <br /> Address <br /> Phone# <br /> Authorized representative ofZip <br /> has(have) been decontaminated an approved <br /> aor certifies by signing below that <br /> tank(s) <br /> Department of Health Services. moved manner as may be regulated by <br /> * * * * * * * * 3IGNATU E AND TITLE <br /> SECTION 3 - To be filled out and signed <br /> treatment, storage, or disposal fby an authorized representative of the <br /> acility accepting tank(s) . <br /> Facility Name <br /> i <br /> Address f <br /> Phone# <br /> Date Tanks Received Zip <br /> No. of Tanks <br /> AUT1'iGRIZED SIGNATURE AND TITLE <br /> NAILING I * * <br /> NS�RC;��pN,g: Fold in half and $� � <br /> staple. Affix properot <br /> Postage. <br /> EH N XX 'WP\�C3FfI'.LET' � <br />