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FACILITY MAHE: Gc��t�� �mR� <br /> PFACILITY ADDE2FSg: ID <br /> TAW DISPWITION TRAaING REOORD <br /> This form is to be returned to San JoaQnin Local Health District within 30 days of <br /> acceptance of tank(z) by disposal or recycling facility. The ho <br /> r with number noted holder of the permit <br />. above is responsible for ensuring that this fora <br /> returned. is completed and <br /> t x x x R x R *. t R R R R R •• � <br /> To be filled out by tank raNOW l contrac _ <br /> Tame Removal Contractor: h�GO <br /> �1. <br /> Mares; r W 0-0 Phone �i'-S <br /> Da to Tanks Reaoved `r- p---' '— <br /> _ No. of Tanks_ <br /> Ssr- <br /> 'ICH 2 - To be filled out <br /> by contractor "docontaainatinq tank(a)": <br /> Tank "Decontaminationu Contractor, <br /> I� <br /> Address�3/ <br /> Zip 9- s <br /> authorized representative of contractor certifies <br /> by signing below that taa(a) <br />.j' has(have) been decontaminated in an <br /> approvedru1er as may be regiil sled by <br /> Depar nt of Health Servics. <br /> 9IQi1►ZLFig J1Np TI <br /> SECTION 3 - To be filled out and aignad by an authorized re <br /> treatment, storage, or disposal representative of the <br /> facility accepting tank($), <br /> Facility Name , <br /> Address <br /> C Phone 1 <br /> Z1P <br /> Da te Tans i 7 of Tanks <br /> AVt�iORiZEp SIQ111TLRE AND TITLE <br /> x x x x x x x R R R R R R R ! R R R ! R R R R t R x x R x t x • R R R <br />�, l9lILING I�O��g: Fold in half and ata le. Affix <br /> F�{ N )C)( Wp P proper postage. <br /> k' �T�W.LRT <br />