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FACILITY NAME: A-4 6,�'��i/� <br /> FACILITY ADDRESS: .; /?G Z�SC_ TANK IDM <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 * Y x t Y * * * * * t * t * t * Y Y * * t * * * x Y * x t t * SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address:- //k"S �f Phone <br /> ll'-� WifiG zip `o� z- '7 <br /> Date Tanks Removed - 12-YF No. of Tanks_ <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address //,ef S"S /4! 1 `I PhoneM (, �2_?-22 <br /> zip 7 <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE 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 (,✓eS :X <br /> Address /� /�1_ �1Q 1121 Phone , 3 22,?J <br /> 4_(i� C/ zip g56937 <br /> Date Tanks Received _ No. of Tanks <br /> SI TORE AND TITLE <br /> WAILING INSTRUCTIONS: Fold In half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />