Laserfiche WebLink
FACILITY NAME: - 7/Af i 1,16 " i <br />FACILITY ADDRESS: LL/ T. TAMC ID # <br />UNDERGROUND TAMC DISPOSITIa 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 />SECTION 1 - <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Phone # <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 />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 />SIGNATlRE 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 <br />Address Phone# <br />Zip <br />Date Tanks Received No. of Tanks <br />AUTHORIZED SIG7A71PE AND TITLE <br />HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N xx WP\TRACSHT.LET <br />