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FACILITY NAME:,6,, fe ��] U ��/t, ��/�i! 7�i DYl CU✓J / l'y <br />FACILITY ADDRESS: / Zi / /G �i /�l7il�I 7l1? lP�/ TANK I D 1 l8'J' �/- U % <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 />* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SECTICN 1 - <br />To be filled out by tank rewval contractor: <br />Tank Removal Contractor: <br />Address:Phone 1 079v��/7S <br />zip 91'5�4Ka <br />Date Tanks Removed / i No. of Tanks / <br />* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br />SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br />Tank "Decontamination" Contractor ; o k ..e_ <br />G <br />Address 0 0 D ifhulyt__p Phone 1 <br />L. n , (' B- Zip 9 5-.2 <br />MV 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 f Service. <br />Vj <br />/ /SIGNAMRE 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 o ts'9as-M <br />Address 'aA1e NOS10:1 OOOZt Phone# <br />Zip <br />Date Tanks Received _ No.,of Tanks <br />AUTHORIZED SIGNATURE AND TITLE <br />HAILING INSTRUICTICNS: Fold in half and staple. Affix proper. postage, j = <br />EH N X3( WP\TRACSHT.LETV� <br />F E B 2 `, 1989 <br />PEf ,% i <br />