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11UBL <br /> 'Ni7v <br /> J11)(11 J(1,1t)11!�d (fit11,'NTMJ)_M.i'11 "� ��lal <br /> VVV {� <br /> .117N <br /> JUN 2 3 19 <br /> Y.l). Box 2009 (1601 hist Ela;:elion Avenue•) x SI,,,!:wil, !Ail(mnia 1)S;:!:;! <br /> (209) 468-310 <br /> tL'NVIRONMENTAL HEALTH <br /> - i1- - UNDI'sRGIZOUND "TANK DISI'OSI"I'JUN '1'I:AC'1�INi; I21:C:OI:1)pERMIT/$ERV!CES <br /> i.k!Y t Y#f►#�,:Y i V!►Y######a#!###########Y#*###:4+:k!t Y###'Y###!Y'V##1 5#Y*.f t 1 4 k#'Y Y!Y-k*#k i 1't 1♦a k k##a!*«##a l Y Y Y Y Y♦a a <br /> 5%CT lON 1`- Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The i. <br /> "i 1m;Ving Sheet is.to be returned to Public I Icalth Services within 30 days of�Icccptattce of rhe tank by the disposal or recycling ! <br /> f,4!+ Iv. The permit holder 11 r sponsible. for cnsulinr, thrlt this forin is complctcd and returned. ' t <br /> _ i <br /> AD[)R FQS: 60 q <br /> ilr.,e- <br /> ' T l r f a a a a#!Y Y 1 1 1#•a f a x!a , a i i 1 #/ I I " r „ � .' 1 Y r 1 ' Y r Y r Y.1 + • , '• Y-1 I I'I # 1 r . "i#'1 1 '.Y r r'r l a a a k t i#+f t s a!+!!!#Y t!# <br /> ! <br /> i I <br /> S'r 110N 2 - To he filled mil h',' iarl: tcrr,c', ;I rr'nu:lk:tc)r: <br /> r ' <br /> i wt'. Removal Contmcaclr: <br /> , I• <br /> I <br /> 1 . . r , l l f.a i.1' P-I'Y i r i r I to- .,i I } r.l I r i I / 1'1 F Y'r I i F i'}{ V r'V:k r'•, f " 1 P k k i a r.«;:/#a!f a! <br /> 1', 1 a r I $ r ., . <br /> ti 3 d <br /> o be filied oilt by contractor econtamu)ating tans. <br /> l atfi t mrlie ion -Contractor: �' {'.i�r, ,.� -- =— -- ' _ ' - 11 :,' <br /> w = " <br /> f. <br /> %, tll;.rized reprc•s:ntative of c0ntrml.or '•.1i1llCd by si(l 111?w hchm. th:li Ow mnl: I1:1s bocil C1ccontaii mated in an approved <br /> liiminC'r a5 required by the State Dc.parin ,:int of I-Ica!(i1 <br /> Y <br /> I �Yttvtalir♦l1# v##M###Y##Yk#ktY11%#ii�+V!!'Yl:H'k k'YV IN i{-.#VY �Y?.Y}1�N#'1#' 4## f�#k##�4'k�('Fi rk 1 �/ <br /> SEC' F!ON •1 - 'i,, . ,: signed :incl ;sated h',' :m nuthurizrri of the treatment, storm'e, or disposal facility <br /> y pttn; lank and/m pwi;lC. <br /> r' <br /> , <br /> 1 <br /> Mt Zip. � P <br /> • <br /> t. <br /> • <br /> I.. r <br /> I, <br /> 1).1,, k <br /> 1 ' <br /> 11 It <br /> 23 0,9 (rev 218/91) Wp _— <br /> A ii:, rlr,.,nrSan Jnim,in. ;l;n i stealth: ac' <br /> v <br /> r P ' <br />