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-pACILITY NAME: <br /> FACILITY AxXUZS: J - <br /> U11NDERGtOUVI) TAMC D S�(k;ITICN TRACKINGThis form 1.a to be returned to San Joaquin HD( tD <br /> � Local Health District within 30 days o£ <br /> acceptance of tank(s) by disposal or r <br /> With n �YClincl facility, The holder of the <br /> umber noted above is responsible for ensuring permit <br /> returned. that this fora is completed and <br /> To be filletl out by tank rewoval contractor: ICN 1 - <br /> Tank Removal Contractor: <br /> Address: <br /> Phone � <br /> Date Tanks Removed Zip <br /> * * * x * x x x x x x * x * * x x s x * x * * * x t f*Tanks--- _ <br /> SSMON 2 - "ro be filled out <br /> by contractor decOntaiinating tank(s)e: <br /> Tank "Decontamination" Contractor <br /> Address <br /> Phone <br /> Authorized representative of contractor certifies b signing <br /> has(have) been decontaminated in an a y �' � below that tank(s) <br /> Department of approved manner as may be regulated by <br /> Hearth Services. <br /> SIGNATUREAND TITLE <br /> SEC TION' 3 - To be <br /> filled out and signed by an authorized representative of <br /> treatment, storage, or dis <br /> poral facility accepting tank(s) . the <br /> Facility Maine <br /> Address <br /> PhoneN <br /> Date Tanks fi:e-ceived Zip <br /> No. of Tanks <br /> AUTHMIZED SIGNATURE AND TITLE <br /> HAILING INSTRLVrI{IIS: Fold in <br /> half and staple. Affix proper postage. <br /> EH N XX WP\TRAC�,HT.LET <br />