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FACILITY NAM:: (�;/ llie5 <br /> FACILITY ADDRESS: 39.3 / 11/c�J � leo U TANK ID t / 7 03 <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 /> z z z z z z z z z z z z z z z x x z z z x z z z z z z z x z z z z z z SECTICH 1 - <br /> To be filled cut by tank removal contractor: <br /> Tank Removal Contractor: /�r K p <br /> Address: T /�G ( h. /\Gf _ Phone f a 0 S �f- 7 foJ�3 <br /> X5351 <br /> Date Tanks Removed No. of Tanks/ 7 3 — <br /> / 7o3 -� <br /> . xxxxx : � : xxxxxxxxxxxxxxxx : xxxxxxxxx <br /> SECTION 2 - To be filled out by contractor. "decontamina� ing tank(s)": <br /> Tank "Decontamination" Con ctor GO p <br /> Address "1 \ �� . �C'�d l Phone q <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has ve) been decontaminated in an approved manner as may be regulated by <br /> De nt o H It ervi3s� \ <br /> ktil <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 <br /> Zip 9 I j <br /> trof'r <br /> ved �1 , <br /> �' No. of Tanks <br /> AVTHORIZED SIGNATURE AND TITLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N M WP\TRACSHT.LET <br />