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Q� �D <br /> ss� R 2 81988 <br /> e - <br /> '�'""�0��� -� ^'►� ei..� g�sa�,o' t,�± 'ENTAL HEALTH <br /> 2-Lodi, OA. TAMC ID 1 ;ENTAL HEALTH <br /> C DISPOSITICH TRACKING RE00RD <br /> (� p <br /> InoV Joaquin Local Health District within 30 days of <br /> o� m recycling facility. The holder of the permit <br /> =01) G✓1 a NA ble for ensuring that this form is completed and <br /> m <br /> N <br /> SE7CfI0N 1 - <br /> °n <br /> 0r atraCtOr: <br /> °y = <br /> e emellos , I <br /> Phone R (209 )369-1132 <br /> igg s Zip 95242 <br /> �a��� � No. of Tanks On© (1 ) <br /> �m <br /> P 5 <br /> g ractor "decontaminating tank(s)": <br /> wN3�m`" Z i <br /> 3 ❑ EDva v �_$ Phone$ <br /> .00 <br /> Sa'o' o o m O mid mz <br /> Zip <br /> m z m;E <br /> a�".33' ro 0_ Tactor certifies by signing below that tank(s) <br /> as" _ o a o= <br /> a <br /> m�amm P o N in approved manner as may be regulated by <br /> n <br /> o TLRE AND TITLE <br /> mEl <br /> go * * x x x t * t f x x t t * * <br /> 00 -d by an authorized representative of the <br /> F'' p Lty accepting tank(s) . <br /> ❑ 00 a <br /> �a CO m <br /> Phone# 456-6875 <br /> CUSTOMER COPY Zip 95205 <br /> Date Tanks Received !;Z)n No. of Tanks (One ) <br /> JCRIZED SIGNATURE AND TITLE <br /> HAILING INSTRCI 0NS: Fold In half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />