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s.x�r J i[,�rrZv r'CoCtAr, <br /> I-rEAL�. t <br /> DI SZ'RI CT <br /> � RMM TANK DI <br /> iSP4SITI0N MUXING RZMRD <br /> t * ft #***rt* * * t*"* tst" *r#t**#**"***#*s*#"*"#"**:"*t*: <br /> SDGTION 1 <br /> affixed With itgslteaid identification Health District's Tracking Sheet will a <br /> Joaquin Local Health District within Znumber,� of Tracking Sheet is to ecomP3ny each t� <br /> recycling facility. acceptance of the tank bbe returned to S' <br /> Ei. y disposal or <br /> es _LU <br /> f'AC UTY mw.. C <br /> fo <br /> FACILITY CESS <br /> TA�q( I U i S On <br /> e <br /> 7U <br /> D 039- ;2 _p - <br /> SECT ION - 2 - .� <br /> J; <br /> To be led out b filled Y tank removal contractor: <br /> Tank''Removal Contractor: <br /> �i <br /> Ad4re, sq• 0. <br /> Telephone: (a PhoneM: <br /> *"* na Tank ltemaved: <br /> SwrION 3 -To be filled out b ",t#"""*ar,rar""�r**tar**"* *#*s <br /> y contractor "decontaminating tin: - <br /> T . 7conta1natiOn" Contractor: 0, <br /> Address: <br /> v S"Ta <br /> �' Phoned Up: 3 �/ <br /> Authorized rePresentative of contractor certifies by signing below <br /> decontaminated in an appra manner as r that the tank has <br /> JV Y regulated by pepartment of been <br /> Health Services. <br /> SEMION 4 - To be filled out <br /> storage, or die �d Signed by an authorized represnetative of "* <br /> i, mal facility accepting tank. the treatment <br /> Facility <br /> mill <br /> Address. <br /> Z <br /> Date Tank Received: <br /> honed Q <br /> .1r <br /> �G <br /> Eli 23 049 121*##*t**Rft* **� <br /> liJJ ?3 0l,9 I?/8d <br /> MAILINGI <br /> N57RtJCPI0N$; IN HALF AND S'rABLR <br /> • AMIX PRWER poSTAM. <br /> �> SAN JOAQUIN LOCA,•HFALTH DISTRICT <br /> ATM: - UNMGRCUp TAW PROGf ley <br /> 0. BOX 2009 <br />• <br /> ST=Uk CA 95702 <br /> 1 <br />