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FACILITY NAME: <br /> FACILITY TAMC ID 1_1? <br /> r � <br /> LMERGRMM TAMC DISPOSITION TRACKING ROCORD <br /> This form is to be returned to San Joaquin Local Health 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 /> SDCrION 1 - <br /> To be filled out by tarn removal contractor. <br /> Tank Removal Contractor: 11-.-1%z r V C E U Ld 4b <br /> Address: E13.:: '�, �2 T a <br /> °�-'�? <br /> _..—cam..-� /� .�' Phone � ��a . � t <br /> Yip r1 � <br /> Date Tanks Removed �?� No of �� ' �:-i:r ':T ,� H7ALTH <br /> Tanks <br /> SEMON 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor_ <br /> Address /3 - 11D-1-wr _PhoneI I <br /> -:r ,, zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Depar-hwnt of ealth prvices. <br /> J / 2 <br /> SIGNAZLRE AND TITLE <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name s 7 <br /> Address .(f 9, J'-s' 1Qa�� �I� Phone l 3 ,�$ <br /> �! .1 r,d - Zip G <br /> Date ived__17a No. of Tanks— <br /> AUPHORI ZED S I GNATLRE AND TI TLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage, <br /> EN N XX WP\TRACSRT.LET <br />