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M <br />k�74K <br />r <br />FACILITY s <br />r ► ' �. <br />r' c` • �r ; i r • • • ; • 4 56W• • t <br />This form is to be returned to San Joaquin Local Health District within 30 days of <br />acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br />with number noted above is responsiblefor • that this form is completed and <br />returned. <br />To be filled out by tank removal contractor: <br />Tank Removal Contractors <br />fix? �2 <br />Address: Phone # <br />Zip <br />Date Tanks Removed No. of Tanks <br />* * x * x * * x x * x * * x * * x x * x * * * * * * x * x * x x * x x <br />SECrI <br />ON 2 - To be filled out by contractor "decontaminating tank(s)": <br />• I e- - • r <br />• <br />Authorized representative <br />_..r:: . ofcontractorcertifies by <br />signing <br />I•.. below <br />has(have) been decontaminated in an approved manner as may be regulated by <br />r- •r+ wn r' <br />r Z Mi 71-10 001 Z I IS <br />SWrION 3 - To be filled out and signed by an authorized representative of the <br />treatment, storage, or disposal facility accepting tank(s). <br />Facility Dame <br />Address Phone# <br />Zip <br />Date Tanks Received No. of Tanks <br />AUTHORIZED SIGNATURE AND TITLE <br />MILIM ,. • r in half and staple. Af f Ix proper postage. <br />EH O • C. <br />