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�. . T _ .-. i i r 1 E � F' <br /> Ak �1 R m <br /> FAC1 LITY NAh(E: P o r t Of St _ N O V 1 3 1990 <br /> nckton roods' o.isr 1nc . ENVIRONMENTAL HEALTH <br /> FACILITY AOOR g; tool Fr ;mont TAW ID pr _ IT/SERVICES <br /> Uoma'OffG/ TANK DISPWITICti ami Tw. rignmP <br /> T113 fora is to be returned to San Joaquin Local Health District vLthin 30 days of <br /> acceptance of tanh(a) by dlsPomal or recycling facility. The holder of the pern:t <br /> with number noted above is responsible for ensuring that thLa form Is Completed and <br /> returned. <br /> ■ ! R t ! ! f ! t f # * i A t t * ! R t ! R R R R R t f f ! R ! R ■ R SACPIGN <br /> To be filled out by tank remwml contractort <br /> Tank Reaov4 Contractor: Oil E u i m e cq S e r v i c e <br /> '?- <br /> Address: Po Box 950 � 209-754- 1808 <br /> San Andreas , CA zip 95249 <br /> Date Tanks Removed._./ of Tanks 1 <br /> R ! ! A t R ! ■ t R t t t R * R t R f R R R R t R t t R t R #—�R t <br /> SOCTICH 2 - To be filled out by contractor "deeontarinatlry tank(a)", <br /> Tank "Decontamination" Contractor N o r c a i Oil cu . <br /> Address f'0 Box 45 Phone# 80C-332-8710 <br /> Denair , CA Zip 95315 <br /> Authorized representative of contractor certifies by signing below that tank(&) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> De twen of Health Services. <br /> suMUte AND TITU <br /> y�„p t t f t f R R f R * * • A * A i R • t A A • A • t A t • t t A A • * t <br /> gOMON 3 - To be filled out and signed by an authorized representative of the <br /> treaUment, storage, or disposal facility accepting tank(s). <br /> Facility "A" Trion le Inc . of Sacramento <br /> Address 3525 - S2nd Ave hone/ 916- 421 - 1� _ 990 <br /> Sacramento , CA Zip 9%823 <br /> Doved r <br /> AL1141CRIZED SIGNATME AND TITLE <br /> ! ! R t ! R R R t t t f f t R ! t * * t R f f f • R t f R R f R A R f <br /> 'A;0 MULIM IN9'iWCPICKSt Fold in half and staple. Affix proper postage. <br /> EN N )D( 1R\TRAMjrr.LET <br /> t <br /> Sic ?By-45r:.� .--FAGE . 003 <br />