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f-11 FACILITY H.W: <br /> ` FACILITY ADORMS: 39.E )V44j 4-em TAMC ID A� 2 <br /> INDERGRQID TAW DISPOSITIal TRUXING RFCORD <br /> This. form is to be rcturned to Sara Joaquin Local [filth District within 30 days of <br /> acceptance of tank s) by disposal or recycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> SEM CN I - <br /> t <br /> To be filled cut by tank ren rel contractor: <br /> Tank Removal Contractor: 10 <br /> Address: Fhone r <br /> 4 : Date Tanks Removed No. o f Tanks 17 <br /> -�7 0 3 W 1 <br /> 03 <br /> • r x x # rr r r r �r x r f x x r r r x r r * r r r r r s x R r x �r * r s <br /> c. SEMON 2 - To be Filled out by contractor "decontaminating tank(a)": <br /> Tank "Decontamination" Con ctor G.7 p <br /> 4 Address :\ ! Phoned <br /> �v <br /> Zip h <br /> t Authorized representative of contractor certifies by signing belov that tank(s) <br /> ham v,e) been decontaminated in an approved manner as may be regulated by <br /> De <br /> ttio <br /> K It erVi a <br /> j:i \ <br /> a <br /> SIGNATLJ E AND TITLE <br /> SECTION 3 - Ta be filled out and signed by an authorized representative of the <br /> 3 treatment, storage, or disposal facility accepting tank(s). <br /> t Facility RM& p, <br /> q.a Address QXW Phone � .� <br /> tv Zip <br /> f Re^ ved No.,of Tanks <br /> r <br /> AVL'fiORIZED SIGNA7.I.RE AIS TITLE <br /> 4i, rxrsrrrrrrrrrrrrrxxr : : * xxxrrraxrscrsr <br /> mmLING USTRUcTIONS., Fold in half and staple. Affix proper Postage. <br /> E EH N XX WP\TFiACSgr.LET <br /> v <br /> is.. <br />