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a <br />S©CTIDN 1 -The San IJLOpal health Districts <br />affixed with its site ifioation rwmber. The Ttacki �t will aopo%psny each tai <br />tloaguin Local Health District within 30 da Sh"t LO is bG returned to S& <br />Jeecycling facility, The holder Of t*%O » of aoaeDtance of the tank by disposal ar <br />FACILITY !10l0i1: <br />FACILITY ADi1Rh'S8:� l �% <br />TAW ID 039 —L �L21 <br />:#s##s#s**ss#!*ss#sssslssss sstsssss*ssss!*ssstlssslsssls� <br />SDCPION - 2 - To be f llled put jW t" Sawa& <br />TM Removal r s 8 M C 0 <br />Address: <br />t <br />,.95351 _. <br />Telephone:209 524-9653 24-96 <br />SOGTION 3 .-To be filled out by DoiltlriL'W tink�i <br />,TW* Daoonta>.inatian" C oaft Ors s B M C 0 , <br />Address: 431 ' est * Hatch Road <br />Mod Ata:_ Ce i orn a Zips 95351 • <br />Authorized representativia of eoritsac�tor <br />decontaminated in aestiiias by &L9M q below that the tank has been <br />japp:cored nwrs as vy be Ugulated by Dapart mt of beaith <br />N" ?,Jw- fl vv-)_ aasviees. <br />sss,ss*:ss#s*sssssa#sssssssslss!!s*ssss#sssssslsssl,e!!llsssslslssssss�tss <br />S=ION 4 - To be filled out and signed by an authgcLamd represnetativq of the ssssssstssssss*sss*s <br />ts"tnent, <br />storage, or disposal facility.&MpVt�p t"s <br />Facility <br />Addsess: <br />Date Tank Reaaiv44: <br />AU2NMZri gIG*AAM <br />s s *ss*sss* <br />HH 23 049 13/08 <br />• Mr1ILING IRSTRVGTIONS: ' fCf�D IM iIALF t#MO 8T�'LTr. Rir'FiX P�� � <br />am aaw" Lam NQi1um DISTRICT <br />AM Tw FROM <br />P. 06 ippp9 <br />WO. WX <br />t y <br />t <br />