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'wage <br /> FACILITY NAME: 7- Q _ <br /> FACILITr ADAMS; <br /> rD <br /> This form is GRO[xYD UNDER <br /> TAW DISPOSITION TRUCKING REC�fl <br /> be returned to San Joaquin Local Health District vlthin 30 <br /> acceptance of tank(s) by disposal or r days of <br /> with number noted recycling facility. The holder of the <br /> �OY+e is responsible for ensuring permit <br /> returned. ng that this fors is completed and <br /> To be filled out # # * # # # # # # # # # * # # # * SEMCIII - <br /> by tank removal contractor: <br /> Tank Removal Contractor: J-. <br /> e <br /> Address: S-/ xQe�(Lh'�/v 1� <br /> C Phors! <br /> Date Tanks Removed 9 zip <br /> No. of Tanks f <br /> #�� w <br /> -'JDMCN 2 - To be filled out <br /> Tari by contractor "d�taminat ". <br /> "Decontamination" Contractor s7; 0 a tank(a) • <br /> Address 801 EB e ..; L <br /> a' <br /> 4-4 D Phone X209 <br /> � C Authorized representative 9 S�Yc3 <br /> ntative of contractor oer <br /> has(have) been decontami tifies by signing below that <br /> k <br /> ��/ ted in an approved tank(s) <br /> DePartmen "of Heal ces. manner im may be regulated by# # * �Tb <br /> SIGNATuRE AND TITLE <br /> SaCr'ON3 be filled oand <br /> ut s 1 <br /> treatment, storage, A by an authorized representative of the <br /> Facility Name RANCHO CO. Pting tanks) <br /> DOVA, CA 95742 <br /> Address <br /> PhoneN <br /> LDateTanks Received Zip <br /> Na. of Tanks <br /> Amwm�IZED SIG MTURE <br /> * * * # * ww AND TITLE <br /> # w * * * www # * w # <br /> HAILINGI * � # ww * w # * # # www * * <br /> 1C.TIOlYS: Fold in half and staple.EH N 7oC Wp\7RAc;NT.LET Affix proper postage. <br />