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' FACILITY KANE: <br /> FACILITY ADORMS: D� ���� <br /> TANK DISPOSITICIN zRbQCI!#C R <br /> 'his form is to be ret:= = d to San aO�quln Local filth District Ulthln 30 days of <br /> accePtance Of tank(s) by disposal ar,rwyclinq facility. The holder of the permit <br /> with number noted above is raap,msible for eraming ext this fosm� is Completed and <br /> returned. <br /> -r <br /> R t t ! SEMCN <br /> To be filled out IT tint re+aral centractor: <br /> Tunic Rei 0"l ceitractar: 3 <br /> �--G zip <br /> Date Tark3 Renoved p <br /> of Tanlc,�____�l . <br /> MCrIOH 2 — To be filled out by Cwtractor " <br /> daContamirnatirtq tank(a)": <br /> Tank "De=ntaaination" ODntrator :m a- e- O' <br /> Addrew <br /> Lig h ` zip <br /> es4 5a Yv <br /> AuthOrUed reprentatives of contractor certifies <br /> has(have) been decor tacit � approved <br /> signing be 1 av that tartl:(s! <br /> Departmen °r I capProvsaru�r are may pr r llatrV1' frf <br /> c d <br /> S1GHATU?S AMD 77TL8 <br /> s8MON 3 To be filled out and si <br /> treatment, storage, E an authorized representative of the <br /> F�cil lty Name PANC"O CORDOvotVA. CA 95742 n4 tank(a) <br /> Addres,� <br /> "s �cx 4 <br /> 'Z'►t" -Z&Nm'1� pZ�, 7 A� � do,,of Tanks <br /> -._. ._.!-..k-..t 11._Y._..�._.t �.._t 6 t t t t i t i t i t t l 1 L \ t \ 1 • ♦ • •. •. <br /> _- ...... fix-.pzoPer. ..._._._ <br /> ...- staples. .. _-....._ _.-...._ --- .. <br /> `,i�.ILII�:• tit �tlC VDId In half aI d <br /> RPP. 4f 3 <br />