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10 <br />0 <br />FACILITY NAME; <br />FACILITY ADDRESS: <br />9so3 <br />�wP- `TANK ID I q q <br />L VDERGROIA•ID TANK DISPOSITION 1RAIXING RECORD <br />This form 1s to be returned to San Joaquin Local Health District within 30 da <br />acceptance °f tank(s) <br />by disposal or recycling facility. <br />with n Ys of <br />umber noted above 1s Y. The holder of the permit <br />returned, responsible for ensuring that this form is <br />* * completed and <br />: x## <br />To be x x:** x:** x x**# S�I� 1- <br />filled out by tank removal contractor: <br />Tank Removal Contractor:_ �1 <br />Address: L <br />3 (pV nk �o2f�� <br />� aL <br />:- , <br />Phone M y d-�o!?J— <br />LG.I�'i <br />Date Tanks <br />No. of Tanks <br />x x x x x x Ik-- <br />scTICti2-To <br />be <br />fllledout *xxrxxx****1•# <br />Tank by contractor "decontaminating tank(s)": <br />"Decontamination" Contractor ,1; .vij� <br />3 <br />Address SSU 1 E 1�c 0 - /� e- <br />�:RrkQn Phone <br />4-6b <br />Authorized representLIP -7 '.4 a -YO <br />P esentative of contractor certifies b <br />haz(have) been decontaminf?ed t y signing below that tank(s) <br />In an approved manner <br />Department of HealtLSe� ces. <br />r ; as may be regulated by <br />SIGNATL-RE D TApI I,'e <br />SECTION 3 <br />To be filled out <br />treatment, storage, °PWL;T3 gnEned by an authorized representat <br />L. <br />Facility Name RANCHO CORDOV/-, C '-957 epting tarilc(s) Ave of the <br />42 <br />Address <br />Date Tanks Recei <br />of <br />* k k k* <br />R# <br />nv1710RIyED <br />SIGNATI.RE AND TITLE / <br />MAILING <br />x k# k* <br />INS'IRuc ONS• <br />k k# k k*# <br />F <br />k### * * # * # # * # * # # <br />old in half and staple. Affix proper postage. <br />EN N XX WP\TRA(SHT.LET <br />