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r.A0CUkT-. MEAT IMCSIrRiarr <br />WWRGRIOUND TAW DIsPosrTI0M TRACKING RECORD <br />.. r .. <br />• y r : r • • • -MMP7W' t <br />cILITY NAME: <br />1 <br />be Out by <br />Iress: <br />-Zip: <br />#O2A 9.yds =VS'G <br />r <br />:MON 3 • be filledout by r: <br />Iress: <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 of Health Services. <br />SIGNATME AM TITLE <br />.TION 4 - To be filled act and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting <br />Iress: <br />Zip: <br />Phone#: <br />:e Tank Received: <br />MY51ORIZED SIGMUM AND TITLE <br />23 049 22/88 <br />LING INSTRUCTIONS: FIOLD IN LUS, An STAPLE. "FIX I PROPHR'PMTAM. <br />SM JOAMNOWALTH <br />DISTRICT <br />i t -i }i TAW ..+#' <br />. 0 ,O r,. <br />