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<rtrrtterufftfftltff tf —�LN ' TJWK ag - ..�,1' tl` •`..••^ <br /> Ytttftftttttt .0i <br /> CIIC1v 1 - The San t*as....•aae - <br /> tixod with its siteoldentiLi�l Health Dlatrl • <br /> Jdjn Local ttealth Di den Catton tuaeber• �a Tri e•sso <br /> pmt v111 <br /> LyclingILupq tfacllity. within 30 days of hat for f t aooep� gq f tt Is to bWMVNV e r sato d to 8� <br /> tach the <br /> by disposal or <br /> -ILITY WE: <br /> 3 <br /> I -ILITy CESS, — <br /> t�c <br /> ;K ID 839- <br /> tt:::tit itt! o be fill, t trttttttlltttttrttttttfllttt;tttltttttlYYYtltt! <br /> j TIS - 2 - To be filled out b <br /> 4 y tank reaoval cantractor: IY:;YIt <br /> -J Removal Contractor: <br /> tress: G <br /> l <br /> o L, C. Zip: �— <br /> ! iephone: (�Og �•— Phone@: ---- <br /> .=trt::lftYtttrrltt��J <br /> Date Tank <br /> e O 6=trYTank <br /> t tttYtf:tl <br /> DBehoved. <br /> r* <br /> t!l <br /> TION 3 -To be filled out by contractor <br /> "decontaainating tank": ::t:Y:Y::att::ltYr;:tt=z <br /> ,k D'--contamination"i Contractor: <br /> tress: <br /> ` r <br /> horlud re Phone/Zip. 2 <br /> esentative of contractor �� �� p <br /> :ontam! in n appro mer certifies by signing <br /> May be regulated bDe low that the tank has been <br /> Partment of Health Services. <br /> 1=a=trtt <br /> SIGMLTMEtffbe filltt;lrrrtrtcrest#ttttttttttftlttttRttttttttfttt;;Y!ltft; <br /> TION TITLE <br /> - To be filled out arld a! <br /> cage, or disposal facility t� by an authorizedttt:YrlttYYY:tt <br /> :ility Mame — Te�eaxtative of the treatment, <br /> tress: C <br /> i <br /> e Tank Received: Phoneyzip n <br /> =tl:st=:trr*lrt:t:tt!!tltttttt <br /> 23 1MLI tttea ;;� tt atttttrttft::ttrr!l:ttrrt;tttr:Y:trl: <br /> ZINC IHS'TRUCfICttg: FCYD IM Hu.P <br /> AM STAPLE. AFFIX pE1IpVR POSTM.£. <br /> 1RAI.TH DISWICP <br /> Pi O. BOX 2009 ANC PROGRAM <br /> 95202 <br />