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FACILITY NAm: LTE6Nfi/' ✓�i b �i ons <br /> FACILITY AD{)RES3:��J�� 211L TAW ID <br /> lliDBR p(� TAMC DISPOSITICN 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 /> SECfICN 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone i <br /> Zip <br /> Date Tanks Rimsoved No. of Tanks <br /> ! R x t t t 2 x t x t t 2 x t ! 2 ! = 2 t t R x x t ! t ! t t t t t x <br /> SELTICN 2 - To be filled out by contractor "decontaminating tank(a) <br /> Tank "Decontamination" contractor <br /> Address Phone# <br /> ZIP <br /> Authorized representative of contractor certifies by signing below that tanks) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> t R R x 2 t f ! t t t t x t t ! R t t t R k k k t k t t R ! t R t R R <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tanks) <br /> Facility Name <br /> Address <br /> Phone# <br /> Zlp <br /> Date Tanks Received No. of TWilcs <br /> AUrHORIZFD SIGNATCRE AND TITLE <br /> R R k R R R 2 R R R t t R t t t ! ! ! t t ! k R R ! R R t ! R t t R ! <br /> MAILING IN37RU-MON3: Fold in half and staple. Affix proper postage, <br /> EH N XX WP\TRACSj?r.LEf <br />