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•�■�rattrttttt�tttlt�ltAt!!!!!t!t!!! <br /> The San Joomi ti!lttt!!�� '�' :�� I � •nr. _�> : ,� . <br /> t ""' with its -site identification kation Nft1a�iet�• �jskeet <br /> !! <br /> ,,I"'n I.oc'dl Ilealth District within 30 days of Ziac it will <br /> � �INt is to br�ra��i of Ban <br /> faci 1 i ty. aDolptil�p Of qr tank <br /> by:' 1f��I ���_ S fOrA St e'r�r►t_� tlrrwit�l diip( 1 Or <br /> "I I.I TY NAW: f �- � Y��►` /i <br /> I L I TY ADOR�sS: <br /> ;K ID <br /> ��:Yitsatttttt tl!llllltltltR#Atlilt/ltttll SIZE'_ _ '�'� �� C7 <br /> r I C14 - 2 - To be f i l led out b RAtARl <br /> Y tank removal contractor: tl l*tllllla*�� <br /> J: Removal contractor: <br /> j�ess: l <br /> Zip: l• .� c= c. <br /> Phone/: `'-"'-- <br /> .: ssal—l-`tl=tt'tRRRltttlt#ttl�l**tin#Removed: ttltlll <br /> TION 3 -To be filled out by contractor "decontaminating taNc": <br /> lftlAttlllllllll#****** <br /> ,k Decontamination" Contractor: <br /> CA <br /> Tress: <br /> p: <br /> horized representative of Phoned. <br /> ontaminated in an appro tractor certifies by signing below 7Na4Y that the tank has bee,, <br /> egulated by D&PRrtment of Health Services. <br /> ctttt3ttttttt!!!!!!!!#lttlt!lttttt!#R�t � tRTITLE <br /> !!t <br /> 710N 4 - To be filled out and signed •ttt#ltltllt#lilt*tttattlt**** <br /> cage, or disposal facility �Y an authorized reptesnetativc of the treatment, <br /> a pting tank, <br /> -pity Name / � -- <br /> cress: <br /> Z ip. --�� -- <br /> e Tank Received: - ` L�z�. P1oneM:4giT- <br /> :�,:,etttllllllttlt!!!!!t!!!t!u t� t �#(tlIMAm <br /> t !'t!'T! ! <br /> 12/81 t!!tA!ltttlttttttl*lllttltl**t <br /> 'rIt+G IN37Rl1C'I'ItHS: FC ,p IM 11it.F am STU". A '!IY ppppU <br /> POBTl1M. <br /> 20 ?0anw LAM It"TM DISMICT <br /> AM MM"aft TAW pi"M <br /> r 0• BN 2009 <br /> 870CXW1, cue► 99.204 <br />