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1 FACILITY NAME: <br /> FACILITY ADDRESS: CTAW ID <br /> 1 INDFRMM TANK DISPOSITION TRACKING REUDRD <br /> This form is to be returned to San Joaquin Local health District within 30 days of <br /> I 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 /> 2 * * * * * * * * * * * * * * * * * * * * * * * 2 * 2 * * * * * t * 1� SDCI'YC1N1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: J ; IL e f'L x C J <br /> Address:� -�.� Al 6e Phone <br /> Zip_ �d <br /> Date Tanks Removed Z2 Z12 No. of Tanks,-1�--- <br /> O <br /> a tr * a * e 0 * 2 * * V * u * a * * * � tr tr � * A it u a Atr tt � <br /> 3ECPION 2 - To be tilled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination00 Contractor rn '_LL a& -.e_ U,L, �•mac <br /> &ddress5'/ A �ec k^1� •� { Phone q 9 <br /> Z-4 p, Zip_4' :ay <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(kava) been decontaminated in an approved manner as may be regulated by <br /> Departine t ` h Seryipes. <br /> j <br /> 7110 <br /> SIGNATURE AND TITLE <br /> V1 e a 0 4 tr V V a * rr * rr n a 4 0 a is a it tr * a a 2 * tt tt tr * <br /> SB=I(ki 3 - To be filled out and signed by an authorized representative of the <br /> treatienta storage,, or disposal facility accepting tank(s). <br /> &CtU;IZEA _,_ r `, <br /> Facility Name_,- .onnF. .T � 1t1 • fit '+S �; <br /> wwcHo-CO.-. � <br /> Address t c _ Phone g a. <br /> Zip <br /> Date Tanks Received Pio. of Tanks��, L t, <br /> Avri miZED SIGM TITLE <br /> MMUNG %NSTRLMCNS: Fold in half and staple. Affix proper Mage. <br /> EH N XX %?\TRAM HT.Li~T <br /> �� <br /> 111VIev <br />