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w <br />C7 <br />FACILITY NAME: V nE-ACzd/ <br />FACILITY :�� / � �` 6 Y' TAM ID # �.2 1-/SWj el 2 - <br />UNDERGROUND DISPOSITION TRACKING RECORD <br />This form Is to be returned to San Joaquin Localof <br />acceptancey.The holder ., the permit <br />vith number noted above is responsible for ensuring that this . completed and <br />M�1M <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />?Y? Address: Phone # <br />Zip <br />Date Tanks Removed No. of Tanks <br />#*#***#**#**#*****#**********##**** <br />SECTI <br />ON 2 - To be filled out by contractor "decontaminating tank(s)": <br />Aillress • <br />. <br />Authorized <br />_...• _•__ of <br />contractor certifies • signing •.•. • . ..: <br />has(have) been decontaminated in an approved manner as may be regulated by <br />rZ P.IV io, Zj V I Z 16WIM <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 SIGNATURE AND TITLE <br />ZLX&M INSTRUMONS: . • <br />