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FACILITY NRM:__� TEPf�C�/ ✓li i„ <,,� - <br /> FACILITY ADDRE : t/CJ,2D 1 f�J67 me u 7y TAW ID 1 -( <br /> LIMEMMMIND TAN( DISPOSITION 1RACKING RIND <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 fora is completed and <br /> returned. <br /> t t t * " ! 2 t t ! R * * ! R t t t t t t t * * * t • ! t t t t t t t SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone <br /> Zip <br /> Date Tanks Removed zi of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decmtaminated In an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNAT(RE 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 <br /> Phonel <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> ALMJORIZFD SIGNATURE AND TITLE <br /> FAILING INSTRUCTIMS: Fold in half and staple. Affix proper postage, <br /> EH N XX WP\TRACSHT.LET <br />