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A <br /> FACILITY NA?0; <br /> FACILITY ADDRESS; <br /> s o TAM ID 1Z2ZL-�eav pj <br /> TANK DISPOSITICH TpVXI iG RECOM <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> aocePtacyoe of tanks) by disposal or riling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> To be filled out SECTZQN 1 <br /> by taw* removal contractor; <br /> Tank Removal Contractor-. Sjsr, G <br /> Address: -? 41 / hone r <br /> zip <br /> Date Tanks Removed No, of Tanks Z <br /> S&MCN 2 - To be ;Filled out by contractor "deconta■inat . <br /> Tank "Decontamination" Contractor tank(a).. <br /> Address �Phonc#20 Sul <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved mariner as may be regulated <br /> by <br /> DepartmInt of Health services. <br /> /Ori <br /> SIMAIME AND TITLg <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(a). <br /> -Facility Name <br /> �Y 5/ Phone#5/ - -060 6 <br /> Zip <br /> Date s <br /> No. of Tanks <br /> ALMMIZED SICN&TURE AND TITLE <br /> MII.ING INSZRUCnONB; Fold in half and staple. Affix proper Postage. <br /> EH N xX Wp\7RA=HT.LV6T <br />