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£. 1990 <br /> FACILITY NAM: �n <br /> ENV If)Q�I�NFrpLTH <br /> FACILITY ADOMM.,�� a- 5 , <br /> A u r og oA- TANK ID 1 10 / S - / ¢Z3 <br /> TANK DIspo$ITIQN F$lUC1CING Rh1D0f2D <br /> This form is to be x*bxnk,t'o San Joaquin Loral Health District vithin 30 days of <br /> acceptance of tank(s) by dlsponal or recycling facility. The holder of the permit <br /> vith number noted above Is renponatble for ensuring that this fors is completed and <br /> returned. <br /> a a a a t a • t ■ • r t r • • • t a a s a a s R a • e t • t t • t a Sk=DN 1 - <br /> To be filled out by tank removal centimeter: <br /> Tank Removal contractor: 1 L 1 j-L /7 <br /> Address: d O G PhoneRMS-t <br /> c->--1. . zip 9 5 i ) <br /> Date Tanks Removed--J. No, of rAnkz__!Z_ <br /> a a a t t ■ t r t t t t • R t r t f a ; t R a a a a • Y a a •It a R a <br /> SWriCU 2 - To be fillmd out by contractor "decontaminating tank(s)•. <br /> Tank "Decontamination" Contractor <br /> Address phonne# <br /> zip <br /> r Authorized representative -of contractor certifies by signing below that tank(s) <br /> has(have) been deeontamioated in an approved canner as may be regulated by <br /> Department of Health n:vlces. . <br /> O L(J''( , <br /> SICHAATWE AND TITLE IN <br /> t • r • t .• • • • • • * t b tm t a a a a a a r a a a t a a r a a a <br /> SEA'rIC1N 3 - To be fillmd out' and signed by an authorized repcesentative of the <br /> treatment, atorage, or disposal facility accepting tank(s). <br /> F.Acility Ndme Q <br /> Address i Pnone��f7L �.�� 1940 <br /> CAI- zip <br /> of Tanks <br /> AIlI OOZED SIGNATCIRE AND TITLE <br /> R R R t t t t a a a • t • R t t a a a a t a a t a a a a a a a a a a <br /> hXILINC INS uc=. OH3: Fold in half and staple. Affix proper pontkje. <br /> E]1 N XX YP\TRACSHT.Ezr <br />