Laserfiche WebLink
cILITY : <br />MK 1 1 <br />r � <br />To ♦ - filled out . <br />y tank removal contractor: <br />T <br />cress: <br />P: <br />r. <br />TION filled . • <br />econtaminating tank": <br />1 . , <br />Iress: <br />rid <br />Zip: <br />:horized representative of contractor certifies by signing below that the tank has been <br />:ontaminated in an approved manner as may be regulated by Department nt of Health Services. <br />SIGNATURE AND TITLE <br />=TION , - To be filled out and signed by an authorized representative of the treatment, <br />)rage, or disposal facility accepting tank. <br />gess: <br />Zip: <br />Phone#: <br />:e Tank Received: <br />WT ttt*stttSIGNATURE ttttt*tttAMtTITLE <br />t***ttt***************t*tttttt <br />23 049 12/88 <br />LING INSTRucTIcg: FMD IN HALF AM STApM. AFFIX PROPER AM. <br />SAN JOAQUIN LOCALHEK011 <br />31ti•c••W TANK •.Ot• <br />• BOX 2009 <br />ST00CM, CA 95202 <br />