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FACILITY NAME: ✓' / a;n vRY 3 /+fin+ w* // S / r <br /> FACILITY ADDRESS: i TANK ID # <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District vithin 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 * * * * * * * * * * * * t * * * * * * * * * * * SECTION 1 <br /> To be filled out by tank removal contractor: <br /> Tar9 -Ye.moval Contractor: Al L M .hash Rr 7- c, <br /> Address: hone d, 25 'U I/ <br /> YJ'Yov Ca �� � Zip 9S6 ) 0 <br /> Date Tanks Removed / O P17 No. of Tanks_ <br /> SECTION 2 - To 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 belov that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTION 3 - To be filled out and sl+7ned by an authorized representative of the <br /> treatment-, 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 /> HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />