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CILITY NAME: <br />C#4i �► �► a <br />NK ID 139---f� am �W99WAW112U-1-11 C15 <br />To be filledOut bY tank removal contractor: <br />ik Removal Contractor: <br />cress: <br />1p: <br />. «• <br />"TION 3 -To be filled out by ;Ztractor.mdecontaninating tank": <br />• • • <br />ire ti®x' Zip: <br />:horized representative of contractor certifies by signing below that the tank has been <br />_ontaminated in an approved swuler as may be regulated by Department nt of Health Services. <br />SIGMTLME AND TITLE <br />TION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />gage, or disposal facility accepting tank. <br />M ity Name <br />cress: <br />Zip: <br />Phone: <br />-e Tank Received: <br />ALMM <br />ZED <br />:**ts::*>x::*st:es**>Rt�restte:stss:*s*sxsss*Ss AND <br />s,rTITLE <br />***s*e,Re*****#�*,�*e***�*#*s*#*** <br />23 049 12/88 <br />LING INSTRUCTIONS: FOLD IN HAIP. AM STMX. AWIX . ER AGE. <br />SAN JOAQUIN LOCAL HEAL+N DISTRICT <br />. a' G1 •= TAW pRoGp <br />• BOX 2009 <br />