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•K <br /> r <br /> FACILITY NAHE: <br /> FACILITY ApDf=S: <br /> sJ- S1 t t� :: TAM ID <br /> TAW DISPOSITION Tpj►cXIN(; RECORD <br /> This form Is to be returned to San Joaquin Local health District within 30 day3 of <br /> aeceptanoe of tanks) by disposal or r <br /> with number � recycling facility. The balder of <br /> ted above is res the Permit <br /> responsible for ensuring that thls farm is completed and <br /> returned. <br /> s s s of t * s s >k rt t * ors * R r< t or <br /> To be filled out by tank remov �ELZ'I CN 1 - <br /> al contractor: <br /> Tank Removal Contractor• � G> <br /> Address: G,/ <br /> /y v hone <br /> --z* <br /> [ate Tans Removed <br /> Of Tanks` <br /> s s * * ok �• of or s s of s s s rt s * * t ! R ! of # ! of of ; * s <br /> SIDCTICN 2 - To be filled out by contractor <br /> Tank � "dacrontausirwtinq tanks)": <br /> "contamination" Contractor <br /> Address ' Phone# C� <br /> Authorized representative of contractor certifies b sl i <br /> has(have) been deooci y 9n ng below that tank(s) <br /> tamlr�ted in an approved manner as may be regulatedDep3r nt of Health Services. by <br /> SIdFATLR E: AND TITLE <br /> SECI`ION 3 _ To be Filled out and signed <br /> treatments storage, or dig lit by ce ting tankd representative of the <br /> Po�sal facility accepting tank(s). <br /> .Facility Name <br /> Rate Zip <br /> s e <br /> No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> or * * * * of * t or or oe s * s s <br /> * * * of or of w * s * or * * * s * * * s of <br /> fQULING INSTRLLMONS: Fold in half and staple. affix <br /> EH N XX Wp\Tpj=HT.LET Proper <br /> Postage. <br />