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.e <br />FACILITY ,1%2Z <br />FACILITY Ss 7?"%C' `� TANK ID # %- /YOO 6-3 <br />WDERGROUND TAW DISPOSITICH 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 foray is completed and <br />returned. <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />1� t Address: Phone <br />Zip <br />Date Tanks Removed No. of Tanks <br />SE M ixv 2 - To be filled out by contractor "decontaminating (s)": <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 <br />Address Phone# <br />Zip <br />Date Tanks Received No. of Tanks <br />P;Jlj• • AN t,S 11 <br />HAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N xu WP` HTeLL" <br />