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R O U G H D R A F T <br />FACILITY NAME: <br />FACILITY ADDRESS: <br />ID # <br />UNDERGROUND TANK 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 />x t x t k x k x*** k* t x x k* t x■ t x t x x t* r x t t t t t SEMON 1 - <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Phone # <br />Date Tanks Removed No. of Tanks <br />t t x t t x t t* k x x t x x* k k* x k* k t* x x* t* t*! t t <br />SEMON12 - 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 below 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 />*** t t t t t t x t t t t* t k*! t k** t x t t t** t t t! t <br />SECTION 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 <br />Address Phnr * <br />Date Tanks Recei <br />of Tanks <br />AUTHORIZED SIGNATURE AND TITLE <br />x x* x k* x** x** x x x* x x k t!* x* x** x t x x t x x t <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N XX WP\TRACSHT.LET <br />s <br />