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FACILITY NAME: <br /> FACILITY ADDRESS: ✓r" �� <br /> Gt Y <br /> TANK ID # Z <br /> �ERCRDIJND TANK DISPOSITION --- <br /> This form Is to be returned to TRACKING i [2D <br /> San Joaquin Local Health District within 30 days of <br /> acceptance of tarilc(s) by disposal or recycling facility. The holder of the <br /> with number noted above is responsible for ens <br /> permit <br /> returned, wring that this form is completed and <br /> x k x x * * x x * * * * x x k * k x x * x * k * # * * * x x # x k * k SECTIGN 1 - <br /> To be filled out by tank removal contractor: <br /> Removal Contractor: <br /> Address: <br /> Phone # <br /> Date Tanks Removed Zip <br /> x x k * * * x k NO- of Tanks <br /> k x * * * * * x x k x <br /> SECTION 2 - Tobefilled out <br /> kx * * * * xxx * xx * xkx <br /> Tank "Decon by contractor "decontaminating tank(s)": <br /> Lamination Contractor <br /> Address <br /> Phone# <br /> Zip <br /> Authorized representative of contractor certifies b <br /> has(have) been decontaminated in an a Y signing below that tank(s) <br /> Department of Health Services, approved manner as may be regulated by <br /> SI VATURE ANDSECTION TITLE <br /> treatment, <br /> 3 - To be filled <br /> treatment, storage, out and signed by an authorized representative of the <br /> Facility Name kor disposal facility accepting tans) <br /> Address <br /> Phone# <br /> Date Tanks Received zip--_ <br /> No. of Tanks <br /> x * * x k X x ACR'LK,,IZED SIGNATURE AND TITLE <br /> PlAILINGTRUX x * * * k x # * * x x k # # # * * * x x x x # x x # * <br /> INrrE T Fold in <br /> EH N XX Wp\'iRACSHT' half and staple. Affix proper postage. <br /> SHT.LE. <br />