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FACILITY NAME: __ ��,efne ([/1z�/1(m.fj(/y+ <br /> FACILITY ADDRESS: �) tf. /Lid q,�/ ; TANC IDR <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 /> vith number noted above is responsible for ensuring that this form Is completed and <br /> returned. <br /> SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: BART00 CONSTRUCTION <br /> ?'h Address: 22580 S . Moffat Rd . phone # cgq_9176 <br /> Ripon , Ca Zip 95366 <br /> Date Tanks Removed 12-13-88 No. of Tanks 2 <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor D/G <br /> Address ,Phone# Zo6/ <br /> GDD/ zip ��z*�® <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminate:] in an a manner as may be regulated by <br /> Department of Heal Se ces. <br /> CTJA AND TITLE <br /> Y <br /> * <br /> 3EL'fI0N 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__ A-C-1( Al �w6/ <br /> Address— l l-1 AC,9 R.-D 4d 716,1J7z_ <br /> h1,D a s fo (-,, ZIP <br /> Dat Recei No. of Tanks 1 <br /> 3IGNATME AND TITLE <br /> * x k x * x * x x k k x x x x * x * * k * x * x * * x * x * x x k * x <br /> NAILING INS7RUCTIONS: Fold In half and staple. Afork postage. <br /> EH N XX WP\TRACSHT.LET 1V/Ja^ <br /> AN 11 1988 <br /> /VpU <br /> 0 <br /> Po' NMs���/c4sqC� <br />