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FACILITY NAME: <br /> FACILITY ADDRESS: <br /> qCERGROUND ?ANC DISPOSITIOH IpUXI G RECORD <br /> to b <br /> This form is e rate to San Joaquin Local Health District within 30 da <br /> aOc�"-Ptanoc of tank(z) by disys of <br /> po3al oz r�-7^cling facility- The }� <br /> with number notedoted above is rholder of the permit <br /> es <br /> returned. ponLsible for onsuring that this form is completed and <br /> * * SE•TI <br /> To be filled out by tank removal caontrac-tor: CN 1 - <br /> TWIk Removal Contractor: �-Emco <br /> Addreas:�� l,1. c Zip pha�a <br /> Date Tanks Rcaoved �'-(� Mo. of Tanks <br /> BION 2 - To be fillod out by contractor <br /> "docontAntnatlnq tarn(a) <br /> Tank "Decontamination" Contractor <,c-,- -n <br /> Addresz <br /> / U Phone# ?may-S2 .3 <br /> .L111�5 <br /> Authorized representative ZiP�I <br /> Of contractor certifies <br /> byhas(have) been decon signing below that tarns) <br /> 3) <br /> in an approved manner as may be regulated byDe Par nt of Hoalth 'Servicea. <br /> * ! * * ! s s ! ! s s s s : ! s lls�l� � *ITf•g ! ! * � ! <br /> SDCTION 3 <br /> - Zb be filled out and signed by an authorized representative of the <br /> treatment, storage. or dice <br /> poral facility accepting tank(s). <br /> 'Facility Name ,� , � <br /> Address L/�q <br /> Zip <br /> Date Z`dnks Re <br /> ami No. of Tanks <br /> AtTI 'QU ZED SI C N&T RE AD TITLE <br /> K�ILINC I�ON3: Fold in half and staple. Affix proper Posta <br /> EH N Xx WP\TRACSHT•.I.ET ga. <br /> } <br />