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FACILITY NAME: R,)PAL Rae S{RTIWi <br /> FACILITY ALt)RFSS: ;) �z-I 814 '- 1I ` TANK <br /> NK ID M1� Iy 'C�cn <br /> UNDERGROUND TADI; ON 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 /> * * * * * x x x * * * * * x * * t * x x * * * * * x * * t t t * * * * SECTION I - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone # <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> t x * * t * t * t * x * x * * * t * * * x t x t x x t t t t * t t x t <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <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 decontaminated In an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> * * t * * x ! * * t ! t * t * * t * ! t x t t t * * t t x * * f ! x <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 /> AUTHORIZED SIGNATURE AND TITLE <br /> t * k * * * * x * * t t * * * * t t k * t k k * * * * * * * * * k * * <br /> !AILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N )0( WP\TRACSHT.LET <br />