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FACILITY NAME: ModeS-�o <br /> FACILITY ADDRESS: M(A I IJ , M t�r-k TANK IDN J 33 3-C�o <br /> UNDERGROUND TANK DISPOSITION TRACKING 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 /> SECTION 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone <br /> #- <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontminating tanks)": <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 /> 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 Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGtNATURE AND TITLE <br /> !AILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N MC WP\TRACSHT.LET <br />