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FACILITY NAM:-ST�/{ S1(�/Oei4/rF <br /> FACILITY ADME:SS:_�{�jSD/() TAW ID / /� -Co <br /> UNOEMMDIND TANK DISPOSITION TRMXING RECOP <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 t t 4 t ! R t 4 4 t t t t 4 t t t k t ! 4 ! 4 t t ! 4 4 t t t ! t gIICN 1 <br /> o - <br /> Tbe filled out by tank removal contractor. <br /> Tank Removal Contractor: <br /> Address. <br /> Phone f <br /> Zip <br /> Date Tanks Removed <br /> R t t R ! t t t ! t t ! ! t t 2 t t 2 2 t ! 4 4 !fit Rft TtntaR 4 t ! 4 <br /> SECTION 2 - To be filled out by contractor decontaminating tank(s)": <br /> - <br /> Tank "Decontamination" Contractor <br /> Address <br /> Phonel <br /> Zlp <br /> Authorized representative of contractor certifies <br /> by signing below that tank(s) <br /> has(have) been decontaminated In an <br /> approved manner as may be regulated by <br /> Department of Health Services. <br /> 3I(�71►TLFtE AND TITLE <br /> SECTION 3 - To be filled out and signed representative of the <br /> by an authorized <br /> treatment, storage, or disposal facility accepting rizedtank( ). <br /> Facility Name <br /> Address <br /> Phone/ <br /> Zip___ <br /> Date Tanks Received No. of Tanks <br /> AVI110RIZED SIGNATLRE AND TITLE <br /> R R R 4 R R ! t t R t 4 t t ! R t t R ! ! t 4 t t t R t 4 R t R ! R t <br /> MM LING INSTRLCMCM: Fold in half and staple. Affixo <br /> Eli N XX WP\TRACSHP.LEP Per Postage. <br />