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FACILITY NAM: NE�)S H�ln 0 -,q6 <br /> FACILITY ADDRESS: �9�� / ) TJ07nr<i5 <br /> C� TANK ID <br /> W TANK DISPOSITICN TRACXING RECURD <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 r completed and <br /> returned. <br /> t : x : ! SzMoN 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> Phone i <br /> Zip <br /> Date Tanks Removed <br /> No. of Tanks <br /> t x t t t ! t ! t t t t ! ! t t t ! r ! t <br /> BION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address <br /> Phone# <br /> Authorized rZip <br /> epresentative of contractor certifiessi 1 <br /> has(have �' � n9 below that tank(s) <br /> been decontaminated In an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNAIWE AND TITLE <br /> R ! R t t t ! t t t t t t t ! R R t t ! ! ! t t f t t t t t t t t t R <br /> SEC'PICN 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 <br /> Phone# <br /> Zlp <br /> Date Tanks Received No. of Tanks <br /> AIIfHCRIZED zlb"ATIRE AND TITLE <br /> t t R ! R R R t x t t t R R R R t R R t t t t t t f R t t t t t t R t <br /> HAILING INSZRUMONS: Fold in half and staple. Affix <br /> Proper postage. <br /> EH N XX WP <br /> \TRAC3HT.LET <br />