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FACILITY NAME: K1 ' e /��L C,� Cl 0 X4/0 ee619� <br />FACILITY ADDRESS: /7,;1-7--5-/ 4 L : �2 ftj-j 7` �,/_ t, &LTANK ID # <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 />* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SECTION 1 <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: Or f <br />Address: 13Sl .<A- Phone <br />ke Zip 6y.: <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 0,1n,7_A o R, p.e_O; L <br />Address 64-A-eXt 4 iflitir.eY,n Phone 7. - <br />Ls -b i , C -A- Zip Vo <br />Authorized representative of contractor certifies by signing below that tanks) <br />has(have) been decontaminateq in an approved manner as may be regulated by <br />DepartmAt of�HeXlth genr..4j4dds. <br />e ,K eS iD <br />AND TITLE <br />* * ;fir * * At * * * * */* * * * *d * * * * * * * * * * * * * * * * * * * <br />SECTION 3/- To be filled out and signed by an authorized representative of the <br />treatments, storage, or di1 facility acc ting tank(s). <br />Facility Name <br />Address 3 3 3 U V- n e Rd Phone# &Z7 <br />1 j,D; / . CA- Zip 15",Ivo <br />Date Tanks Received i 'ad ` No. of Tanks <br />AUTHORIZED SIGNATURE AND TITLE <br />HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N XX WP\TRACSHT . LET t E B 2 7 1989 <br />ENWi C i'�ci�iFti! lii.r'�LIH <br />NRM' 'I i SERVICES <br />