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0 <br /> FACILITY NAHE: RA''CII�{ �UR,aI EiZe StATIDAJ / <br /> FACILITY Aln:itl_iS: .-a-4 ' '(4 ` 1 I TANK IDM �9- 14f�-L+c0 <br /> LtMERGRO.ND TANK DISPOSIT ON TRACRINC 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 t * * * * * * * * t * * * * * * t * t * * t * * t * * t * t * t * SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: T, M TtioRPe ()il, SNC <br /> Address:3Sl N Sec tnAw12o(. POBOX3S7 Phone <br /> lvDi C/t Zip �53�!l-v3S"7 <br /> Date Tanks Removed la No. of Tanks_ <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor .5� " 1 <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 Heal �' — - --- - -- - - - <br /> SITITLE <br /> t t * # t * t t t t t t t t t t ! t * ! t t R t R t t t ! * * ! t <br /> SECTION 3 - To filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facilitiiy accept�.ng tank(s). <br /> TEEL PC <br /> Facility Name SCHNITZER1200 FOLSON B�LVD.S C <br /> RANCHO CUKu <br /> Address 958.995-4910 Phonet <br /> Zip <br /> Date Tanks e S Ot86996�58 of Tanks__ <br /> A VAIa V40810:1 0M <br /> 'M U M MA T771R H7711NH'SC <br /> AVPHORI M) SICNA11RE AND TITLE <br /> * # # * R R 2 # * * t t ! t t * t t t * ! t ! ! t * t t t * * ! t # ! <br /> !AILING INSTRIXTICNS: Fold in half and staple. Affix proper postage. <br /> EH N XX HP\TRACSHf.LET <br />