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• � j <br /> FACILITY HAM,. Y r' 170`1 <br /> FACILITY ADORbSS. -2c C�� I (SNC t tea: Lc TANX ID i <br /> 12i0FRMOUND TAMC DIWWITIC H TNG REQ <br /> This form is to be returned to San Joaquin Local Wltn District within 30 days of <br /> acceptance of tank(a) by <br /> disposal or recycling facility. The Solder of the Permit <br /> with number noted above la responsible for ensuring that this form is completed and <br /> returned, <br /> To be filled out by tank zeaoval contractor: <br /> 'Dank Removal Contractor: para(liso Construction Co. <br /> 415/562-55111 <br /> Address., 9220 "G" Street phone <br /> Address., 1_...----- <br /> � akland CA Zip 94603 <br /> Tank$ 12/30/88 No. of Tanks.One y(Cli�° <br /> DateI- <br /> t <br /> aMMON 2 - To be filled out by contractor "dscontaninating tank(a)": ,) (� 2 <br /> Tank "Decontamination" Contractor H&H ShiP ;.ii ->;',iGJTA! IIS;:LTH <br /> Address <br /> 220 China Basin Phone! 415/543-4835 PERIIITISER'dICES <br /> San Francisco Zip 94107 <br /> Authorized representative of contractor certifies by signing below that tank(a) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> i <br /> Departmen o services. <br /> ' SIt21A'I�JRE ANDAND TI �� <br /> t R f f t t t t t t t t t t t t t t t fi t t Y t t R t t • f R t 1 f R <br /> swrlw 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank( ) • <br /> Facility Name H&H Ship <br /> Address <br /> 220 China Basin Phone, 415/T,543-4935 <br /> San Francisco zip 941-- 07—� <br /> ¢ate <br /> 12/30/88 No. of Tanks One <br /> Tanks <br /> IZ:D t R R R R C�1A7LFiE <br /> t t f i f R R t t t R t e t R t t t R R k R t • R y R R /�' <br /> MAILING INSIRI=0t1s: Fold in half and staple. Affix proper postage <br /> SH N xx WP\MACSKr.LET <br /> Z <br />