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FACILITY NAtE: �HC�tJS --- <br /> FACILITY ADDRESS: EfQ2L-14y—_ PO TANK ID i_ L�Q ,' `� <br /> D TANK DISPOSITION TRACKING Rip <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 * t x x x t t t x t t t t t t x t x t t x x t t t x t t t t x x t t � 1 _ <br /> To be filled out by tau* removal contractor: <br /> Tank Removal Contractor: <br /> Address: <br /> Phone 1 <br /> Zip <br /> Date Tanks Removed Ho. of Tanks <br /> SECTICN 2 <br /> - To be filled out by contractor "decontaalnating tank(s)": <br /> Tank "Decontamination" Contractor <br /> Address Phonel_ <br /> --------------- <br /> Zip <br /> Authorized representative of contractor certifies <br /> by signing below that tanks) <br /> has(have) been decontaminated in an <br /> approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATLR9 AND TITLE <br /> e t t t t x * t t t t t t t x x x t x x : • t t t x x r : t t t t : x <br /> SOMON 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 /> Zip <br /> Date Tanks Received No. of Tanks <br /> AVTHORI. SIKrIAT1A2E AND TITLE <br /> R R t R t R f x x R t t x x t R t f t t t t t i t t t t t t t t x t R <br /> HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSuT.LET <br /> —r_=--�.^------='�"s__--�r------•mac.'-- - ---.-�._�_.::_-- -'.---�'—".---�-"�-c:_.—-- _. — -- <br />