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1 - Fa�N .?42�C1U2 N LG7��r• fif�:Al'. TH I7I S'Y'K=C'3! . <br /> U4U) .CJD TMMC DISPOSITION TRACYL)-J=D <br /> II �a�t�aataa�*t*tst��+�tYrtft#et,�ttxtx*x*ttwxt*RKRw.*#rwww�rwwwrtrwaw��r�w�rtr+��rttttf�rNw#r r <br /> k 8�':•!`�uN :. - The Son Joaialn Local Health Dia►xict 9,i Tri-,_.1 req . amt vill accompany each tw* <br /> :fixed with its site id•,ntification number. The Tr `� �# atswet is to be raturned to San <br /> o.ggain Local Health District within 30 days of aeoey�l the tank by diapamal or <br /> •c;rrlirrq facility. MA holder,,Qj the W-MU ' .��l ,JA rssnonsible for <br /> -Ir-ing that this form U .. -.`w i} <br /> FACILrITY AM61LU <br /> i .t <br /> f �hCILxTY ADSS: q" <br /> +s I j <br /> 1. TANK ID M39•_ / w •"C}- -� <br /> SW?ION - 2 - To be- f i l led out by tank rawval contractor t <br /> Tanis ReawyVal Contractor t ,rt�- ; Ei.li.;^;F i L ''w2 H <br /> Address s Ir"r � �a s� Ing <br /> -_ <br /> hovel: <br /> � <br /> 'lie le ore z Ply [ .lam?.. ._ -- Date Tank 32emOved:i <br /> � www�x#s*****wy, ;•�•�,r*tt*t*w*�eRwwwww*x**�tw�rRx�r�rRw***w*�rw*w*Rw�,r�e���i1i1��C1i�n1iSSIiS it1K>r'#tiitilCi <br /> 1 -�.wr�w. r �r M4. r�rrYY Y..r. Yr �.VaML.f�w6 "1ACTliL/11A/M1/1p4�i1� ��[ a . <br /> l <br /> , <br /> Tank Decontamination" Contractor:. �20'ekx-A�Aj <br /> APIi <br /> + Authorized representative of contractor certifies by signing below that the tank has been <br /> j� d000ntaminsted . an aqW MaNiar. as be regulated by"Department of Malth Services`. <br /> # ,y <br /> r. IGNATURE AND TITLE <br /> #R**Rtt:R#R*#w**wee*ww*wRwwtxert�rwwww w#RR#**err#ww�*tr#xw>xx#tRrR*tRtR#+ear##*###*ttt:*######at*Rx <br /> EWTION 4 - To be filled out and signed by an authoriz;d reps: esnetativ+e of the treatment, <br /> sta;x", or uit.�w-tl facility accepting tank. <br /> { Facility Name AME -TC AN mEZLL RECYCLINQ _-INC <br /> ..- - - - - <br /> Address: CA ZLs 91761 <br /> 71=000 <br /> Date Tank Recs34vedt_EEBRUARY 21 , 19U - .1JW0. 500Q F°r Al ]r'ON 7-AZ,5 — I <br /> AUDIUKAxZU siGNATUM MD;JTITLE <br /> Rww ##wwt## Re8� e#ie#+rerw*e�w**wwR�rRR�rwww:twwwww*,rw#w�rr�eww�wwx*�e�e##�r**#,rextt#wtxtt.rR*�ret�t#tw#tw <br /> E EH 23 0I4 x / <br /> M&MING INSTRtX."1'ION3 F= IN HALF AND STAPLE... AFFIX PRCiM-PQSTAM. <br /> SAN JOAGUIN LOCAL. HEALTH DIMiCT <br /> ' ATT: UNDERGROM TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKT Nt Ch 95202 , <br /> TOTAL P . 11' <br />