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FACILITY NAME: <br /> UN <br /> 60-C- ZQ <br /> FACILITY ADDRESS: r <br /> TANK ID <br /> UNDERGROUND TAMC DISPOSITION TRACKING RECORD <br /> This form is to be returned to <br /> San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or re <br /> with n ding facility. The holder of the <br /> umber noted above is r�pcxtgfble for ensuring permit <br /> returned, ng that this form is completed and <br /> To be filled Out by tank removal contractor: SECTION l <br /> Tank Removal Contractor: <br /> Address: <br /> tz' <br /> _ Phone � <br /> Zip <br /> Date Tanks Removed <br /> Na. of Tanks <br /> SE=CN 2 - To be filled out "decontaminating by contractor c.�ontaminating tanks)": <br /> Tank "Decontaaaination" Contractor <br /> Address <br /> PhoneR <br /> Authorized representativeZip <br /> of contractor certifies b <br /> has(have) been decontaminated in an a Y signing below that tan (s) <br /> approved manner as maY be 'regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITL.B <br /> SECTION 3 - To be filled out and s i — <br /> treatment, storafined by an authorized representative of the <br /> ge, or disposal facility accepting tanks). <br /> Facility Name <br /> Address <br /> Phone# <br /> Date <br /> Tanks Received Zip <br /> No. of Tanks <br /> AUrHORI ZED S I GNA7UZE AND TITLE <br /> HAILING IONS: Fold in <br /> half and staple. <br /> EH N XX WP'� Affix proper postage. <br /> 'IRAC�i�tT,L.E"I' <br />