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f <br />FACILITY - <br />FACILITY ADDRESS: <br />ID 3! r~ <br />This form is to UNDERGROUND TAS DISPOSITIf1N TRACKING R�p� <br />be re' -Corned to $� Joa <br />acceptancetank (s) by <br />weer <br />of quin Local Health District within 30 <br />disposal da <br />with n Poral or recycling facilityys of <br />noted above is res y• T� holder of <br />the perm <br />returned.* Ponsible for ensuring that this form is complete it <br />arxi <br />To be filled <br />i l led out b * * * * * * * * * * * * * <br />T� Removal y tank -removal contractor. * * S TION I <br />Contractor: <br />Address: <br />r. Phone � <br />Date Tams Rived zip <br />* * * * * * * * * * * * * * Ik * * * * No. of Tanks <br />SaTIOtrT 2* * * * * �— <br />To be f i l lead out * * * * * * * * * k * <br />y contractor "decontaminating tank(s),,: <br />Tank "Decontamination" <br />Lamination" Contractor <br />Address <br />Phoneik <br />Authorizedrepresen zip <br />presentative of contractor <br />has(havebeen d certifies by signing <br />k <br />econtaminated in an a `� ng below that tank(s) <br />Department of Health Services, Pproved manner as may be regulated by <br />* * * * * * * * SIGWtl E Mp TITL„E <br />SECTION 3 - To* * <br />be filled out and signed b * * * * * * * * * * '� <br />Qatment, storage, or disposal facilit Y an authorized representative <br />Facility Name y accepting tank(s), of the <br />Address <br />Phone# <br />Date Tanks Received Zip <br />No. of Tanks <br />* * * * * * * * * * * A[1i 40R I ZED S I GNAIUR2AND TI TLE <br />* * * * * <br />HII.II.2lVG INSTR * * * * * <br />NEli C"S: Fold in half and s * * * * * * * * * * * # <br />WP\TRACSNT.LST taple. Affix proper postage. <br />