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IT <br /> SAN JOAQM COUNTY"LIC HEALTH SERVIC" <br /> VfVMONMLNFAL H1rALTH DIVISION <br /> LWDptCROUNi 9TORAGF TANK DIS"MON YRACkRiG RECO vD <br /> .i.000G....v._._-GG.av-va-:.. .. _ .. ♦s..................•...•........•..•...•...• <br /> eeaTaidi i • t•uoiie Nj1WW- Uf't— cuioiduuiiiNi lllmti DivislOn`-..aw T=1---- Sh:•! !�L''t ...1.'--h .ffrM with <br /> .D. Trpeb:.. shat(',M tT m.Lreedr'I Iva F"Amnmeetd Health Dfvimirm <br /> ..I.►_�ut,r_n!:r.y.._L.{.!r_ttv�►My rhAl...,...t "r rrryen"a hr ill", The "Mbi holder is reaoortaible for emoting that <br /> !M.lnrw!L rmnNe+wl feA MnenM. _e _ <br /> FACILITY NAME: iuccu-rH <br /> FACILITY ADDRHSS: /,3 <br /> IANi{ iae,19T<r:Ts: <br /> -�(d 1 IAI'rIR JILC�a^t.�1'�4• _�RFri liivi Tn�.X C <br /> -----------a.a...........N.......................aa....u.o....a............1...0.............«...I..H <br /> SEMONI f- Ta t~ Rl!•a mn b; wm~p.., <br /> 1 -�'e�s_•} '�rR�Jle� _Srt�nGtJ �E�- Cih-�.t. . <br /> Tank Removal CatttaetM:$-'ter .._.. <br /> Addreu:Az- ^L _r Ira C f r,T-- cim-x; lV lf-rtJlip <br /> •r �_ <br /> pnox F:cYu / v �w,set s uatc fent Rcmn,ca: --- -- <br /> :<::<:.= ---------------I....................................... <br /> SEMON 3 -To to r ry wi by cuaiPi m "dccon.m.:.-mann <br /> 1. Ut- <br /> Address:RMIK D. L440014.=' �� T— , _ cinar�x_l�tr�ti _zIp: <br /> phos is <br /> Atuborized tepteremave of eenirmfor certify*throvSh sipmfure below that :he 1xi t . been decoatamirlated in wt appiu+amu <br /> mearltr as M"r*d by Cal 6►A. <br /> Nam. lkPi / Tra6l� tr i;..;W, c_r•S'Z %'fq <br /> •G..e.N.A...e.Meh...1.M..e.....�...111............GG.I.......a.....GG1....Ga1.......1...GG........N• <br /> t1l:7Tr1N _ T..hoaMa awes Am"M aw�MhnrlrM r*nrwnrerh.of the treatment. smta[e. of disptnd facility <br /> rscept"tank mover P"! <br /> Faeiliry Naas. <br /> A fAreu: -I4e7. -1/+44 g u-r- s�7 �_ ctry-�yta S�.L Z P �o t✓ <br /> pheee r. t z.r.><y>. �'fa a —'-f'�7 0 <br /> Does Telt Reeeived: j 44 <br /> ."100......^N.NN.....H....N.................u.......L..........b.................N..uwpN.. <br /> EH 23 046 (Reviud l0/19ry6) P28C to <br /> _o d <br /> aO:TT 000?-0r-adh <br />