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FACILITY AZZ /3';1 <br />FACILITY S: / % T ID# - -/ <br />WDERGROUND TANK DISPOSITION TRACKING RECORD C/0 000 <br />This form is to be returned to San Joaquin 1 Health Districtvithih 30 days o <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 />**#*******************************SBCTION 1- <br />To be filled out by tank removal contractor: <br />Tank Removal Contractors WESTERN METER SERVICE <br />tti1;�t Address: Teepee •, $e. • <br />Phone # t <br />Zip - _ <br />Date Tanks Removed _ / 2 `�- ,Fe No. of Tanks 3 <br />*********************************** <br />S©CPION 2 - To be filled out by contractor "decontaminating tank(s)": <br />Tank "Decontamination" Contractor_ WESTERN METER SERVICE <br />AddressPhone# Teepee2735 ., . <br />CA 95205 <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 />De rtme -of Heal ervices. <br />SIGNATM 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 />IWLING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />