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FACILITY NAME: <br /> FACILITY ADDRESS: 22 t F{Zk Ave TAW ID #_3 9-�C'I3- COC' ( <br /> �}�, <br /> WDERGROWD TANK DISPO(AN�SIT10N TRACKING RECORD <br /> This form la 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 /> * r r t t x * x x k t k x x t t t t t x x x * x x k t x x k x x * x x SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor <br /> Address: Phone I <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> f t * x t x t k x t x k x * k * * k t t x t t * t x t t x x t t x R t <br /> I <br /> SW-MCH 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor <br /> Address Phones{ <br /> Zip <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 /> SIGNAW E 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 Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> ALMMIZED SIGNATURE AND TITLE <br /> x x k t x x x x * t t x * x x x t k t t x x * k x x x x x k x * x x x <br /> !AILING INSTRUCTIONS: Fold In half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LEP <br /> t <br />