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R <br /> r <br /> F <br /> SAN JOA,QUIN COUNTY PUBLIC EMALTH SERVICES <br /> M4vmONNUfrAL BMALTA OIY TR2wCXI�i G RECORD <br /> UP(DERGROUN]) SSORAGE TANK DISPOSITION <br /> rra-srwrs..rrr•'��+•ia.t.....YY.fs..a-r.sor...rra.Y�rr+.rm.r..a... <br /> .rY...-++-.r..r....•+••«•r••Y• Xealth Division Tank Tne!dag Shea shalt==Pavy each tank dffiaed <br /> [Y <br /> SECTTOI - Public Hctlth Servicesto Public Health Sel Environmental Health <br /> with its site idcndf=doam3mber. The TankT���` is to be reruraed fac�Y The Pam t hal is resparsibie for <br /> Divisum within 30 days of accepe�of the tank by the disposal or tecyclia6 <br /> ensar that this form u completed and teatrnel r- <br /> FACILITY NAME.'_�c <br /> FACILITY ADDRESS: S <br /> Z 1�1�.�- S¢�-50 0 PRpvtOUS YK <br /> TANC6N'u^I S:W <br /> \ K ID n - T t ......... -- .- <br /> ... ._. <br /> -w....-�.w.#...rrrvma».®•i••"••r••r..v <br /> A.e..-Y.a.r Y.Y.. <br /> a.4YY.."rYY <br /> SECTjOrt 2 . To be filled out by tank-,cwGval coattaCnr <br /> Tank Removal Con.•r.cmr —. <br /> Address: V.:1t <br /> 0ACity: \�n= • C Z p: <br /> C� %,� - C•��C bac Tack Removd: <br /> P'ione X: <br /> ......�..Y........-.mr-m-------- - <br /> SE=ON 3 -To be nl:ed out by coamtzor "dewttmmiaatfa6 tank": <br /> c� w F SG c.i Ccry .c <br /> Trak Dec=t ^La=aa Cantrsror:�._ \ <br /> ectrctnared s>n y7ara`/� <br /> si below dint're tmk.las bre do <br /> Ayttotiad eve of feel cafYtai�n8h l� <br /> manner as 'ecturd'ry CA Ea A. <br /> vamc T tle ------.-. <br /> Y...------- --- m avthorixed reu�eaatdve of dse �cr'storage or yma�l Wclirt <br /> SZCTIW s - To be signed and dazed yY <br /> acting =nk=&or piping• <br /> wtTtc1, <br /> Fsclir/Mame: 1 1s7 V L <br /> t� �Du I C"" Mt•{ CSV:R.�.�p Ctnvt�?Z�: T <br /> Andress: Z 000 ♦y,tolt't — .. <br /> P`ane l- l q 1 ) O <br /> ai <br /> Da'c/e Tank v .Y-.-Y.......'....m� <br /> .. 1•��' <br />