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FACILITY NAME:_ �� �, o Ali l e <br /> FACILITY ADDRESS:_j T 5 , A TANK ID # <br /> UNDERGROUND TAM( DISPOSITION TRACKING RECORD <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 /> t * * k * * x x x X x * * x x x * * x x z * x x * x t k * x * z x t z SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone # <br /> Zip <br /> Date Tanks Removed No, of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> 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 /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> X x x X X x x * x X t x * x * * k * * * k k X x k X * t * * t x x * k <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 <br /> Address Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> x x x x * * x x x * * * X x * * x x x x * x x z k * * z * x * x x * x <br /> HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />