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CILITY NAME: <br />r�-c-�• r r •• • - ` •:psi• -!KM 14 77M. It <br />D <br />"TIONTO <br />be filled Out by tank removal contractor: <br />ik Removal Contractor: <br />/ w <br />--j)ate Tank Rem . ox <br />• ♦ • <br />• • , <br />v <br />cress: <br />C. Zip: <br />Phone #6 .?a 6 <br />:horized representative of contractor certifies Dy signing below that the tank has been <br />_ontaminated in an a r as may be regulated by Department nt of Health Services. <br />3IAM TITLE <br />MON 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting <br />M ity <br />Iress : <br />Zip: <br />PhoneM• <br />:e Tank Received: <br />AUTHORIZED <br />s***ass************eTITLE <br />23 049 12/84 *********** <br />LING INS IONS: FOLD IN HALF AM STAPLE. <br />AFFIXPROPER/�POSTAGE. <br />. . <br />SAN JOAQUIN LOCRL HEALTH DISTRICT <br />tr7'r"i l! TAW •••ts <br />•- 0- BOX 2009 <br />