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SCV <br /> ' <br /> 17 <br /> FACILITY NAME: �� o n1 I C liDrn P'4Ny <br /> FACILITY ADDRESS: UJ . V'J���z�� i TANK ID II 2 <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 /> x x x x x x x x x z x x x x x x x x x x x x x x x x x x x x x x x x x SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> �S�Jn 1 .� <br /> �. Address: hone t <br /> Date Tanks Removed oZ- 7— U5 No. of Tanks_ <br /> x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x <br /> SECTION 2 - To be filled out by contractor "decontaminating tans)": <br /> Tank "Decontamination" Contractor U f <br /> Addressq'� I W�-y 4P,-TcAPhone# <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 /> pe ntrorlU:zvf ces. <br /> Q �� �, <br /> SIGNATURE 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 <br /> `` s� ' <br /> Address `tom\ ') Phone# <br /> T-0 zip <br /> Dat s ReQcei ed — 1- No. of Ate_ <br /> ALnjMjZED SIGNATURE AND TITLE <br /> NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET 8� <br />