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LI Lawrence Livermore National Laboratory Site 300 <br /> FAMLITY ADDRESS. P.O. Box 808 L-871 ID I 875-_31R <br /> evermore UZ6�� TAW DISPOSITIC14 <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of (s) by disposal recycling ility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed <br /> returned. <br /> ! s l s s s s s s s s s s s s s s s s s s s s s s s s 2 s s : s s : : SBMCM 1 <br /> To be filled out by tank removal : <br /> RemovalTank Contractor: <br /> e C f <br /> Address <br /> e <br /> Zip <br /> Date Tanks F No. of Tanks <br /> : ssssss : : : : : sssss : : ss : ss : s : s : ss : sss <br /> sWnCti <br /> 2 - To be filled out by contractor Odecontaninating (s)": <br /> Tank " i tion" tractor <br /> Ph 1 <br /> Zip <br /> Authorized representative of contractor certifies by signing 1 t (s) <br /> (have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SI TITLE <br /> sEMON <br /> 3 - To be filled out and s!gned by an authorized representative of the <br /> treatment, storage,, or disposal facility acceptingtank(s). <br /> Facility Name <br /> Address P $ <br /> Zip <br /> Date Tanks i No. of Tanks <br /> AUnMZED SICNA71M AM TITLE <br /> � * : sss : s : ss : : s : ss : : sssss : s : : sss : sss <br /> MAILM <br /> =I : Fold in half and staple. Affix proper postage. <br /> EX N XX WP\7RACSHT-LET <br />