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FACILITY NAM: California Arronia Co. <br /> FACILITY ADDRESS: 22C1_ °!. .?ashin�:toc "toc,kton TAW ID # IJniciotm <br /> UN�MND TAMC DISPOSITION TRA€KING 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 /> Tb be filled out by tank removal contractor: <br /> Tar' -�-moval Contractor: rior�-h al Construe ion <br /> Address: P. G. Box 5HNor <br /> Phone # 465-58 b <br /> Stockto , Ca. Zip 95201 <br /> Date Tanks Removed No. of Tanks_ <br /> BWTICN 2 - Tb be filled out by contractor "decontaminating tank(s)": <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 /> SIGMA?LRE AND TITLE <br /> r * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> ' TION 3 - To be filled out and signed by an authorized representative of the <br /> :reatment, 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 /> AILING IHSTRUCTICNS: Fold in half and staple. Affix proper postage. <br /> H N XX WP\TRACSHT.GET <br />