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I.r <br /> r SP <br /> FACILITY NAHE• <br /> a. <br /> FACILITY ADDRESS: TANK ID 1 -01 <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> r.. <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 /> vith number Noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> lo, t t t : * s t * * x * * * * * * * * * * * * # * t * * * * * SECTION 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: ' ;rrl IAOPee. e5;z- <br /> --- <br /> t Address: /Q Phone ': -1,17f-' <br /> Date Tanks Removed No. of Tanks,_ <br /> Lo SDGTION 2 - To be filled out by Contractor "decontaminating tank(a)": <br /> Tank "Decontamination" Contractor Z. e U -L <br /> Address-3 5-/ N, /�ee km •✓ _/�Phone9 9 4�-&12Jr <br /> LO 2 i p -- <br /> 4, Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved wanner as may be regulated by <br /> I <br /> Departme,p ,t)► Servipes. <br /> LM <br /> SIGNATURE AND TITLE <br /> SECTIOtl 3 - To be filled out and signed by an authorized representative of the <br /> treatAent, storage, or disposal facility accepting tank(s) . <br /> y Facility Name scri�.ri Zc i-k;fy����.�` �' �Ji <br /> RANCHO <br /> Address _ fl s c; - —Phone# JIM <br /> Zip., JIM <br /> Date Tanks Received No. of Tanks <br /> Iwo <br /> AUInMIZM SIGMTLW4M TITLE <br /> Ln <br /> WAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> M <br /> ,MOW Eli N XX WP\TRA(SHT.LE'T <br /> Ir <br /> na <br /> ` �7 <br />