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• 0 <br />FACILITY NAME <br />FACILITY ADDRESS:e`4 G - ��'Jr �P� TAN( ID 1 <br />UNDERGROUND TAN( DISPOSITION TRACXING 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 />R R * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Sp(,`7'ION 1 - <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: O z__ :/ / /_ Ig r".) � () n <br />Address: 1� ��� �') JY l �w 1/ "% �lJ.c Phone 0-7 <br />c �V Zip y) �— <br />Date Tanks Removed No: of Tanks <br />t f R f R R R R t R R R* R t t R R R** t t* R f R t R* t t f t R <br />socTION 2 - To be filled out by contractor "decontaminating tank(s)": <br />Tank "Decontamination" Contractor <br />Address _, _Phone$ <br />'Lip <br />Authorized representative of contractor certifies by signing below that tank(s) <br />haa(have) been decontaminated in an approved manner as may be regulated by <br />Department of I th S/erv"s. <br />SIGNATURE AND TITLE <br />t f t R R• R t f R• R f f R t R* R t t* f f f* R t t R R t t t <br />sOCPION 3 - To F- f.Ile out aril ,aiyrxrl by an authorized representative of the <br />treatment, storage, or disposal facility accepting tank(s). <br />Facll <br />( 61 <br />'Lip <br />Date -ranks Reef ved ^ , 2 No. of Tanks _ <br />.<..rr,o.u� 0 b 1i <br />e <br />ALMURIZED SIGNATURE AND TITLE <br />R R R R* R t t R R R 4 f t R R f R f R R R R R R R* t R t* R f R f <br />MAILING IN T RUCTIONS: Fold In half and staple. Affix proper postage. <br />EN N XX WP\TRACSHT.LET <br />1 <br />