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f: - - - " <br /> MNI <br /> J <br /> -PAGILITY MM <br /> d" FACILITY ADDftE$S: 14 no. <br /> R TANK ID I1 -wry" <br /> LHDERCRa= TANK DISPOSITION TRACKING RM)RD ) <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptjnce of tank(s) by disposal or recycling facility. The holder of the permit <br /> with number r-oted above is responsible for ensuring that this form is completed and <br /> returned. <br /> * z * * * * k * * * * * * * * * * * * * * * * * * * * * * * * * * * * SECTION 1 _ <br /> To be filled o4ut by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone I <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> r <br /> r <br /> SEMCN 2 — Tb be filled out by contractor "decontaainating tank 00": <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 /> * * * * * z * * * * * * * * * # * * * * * * * * it * * * * * * * * * * <br /> SECTIO{ 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 Phonel <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> A[II`f10MED 91WATURE AND TITLE <br /> +� \ti <br /> H7lILINC INSTRtJC.TICN9: Fold in half and staple. Affix proper postage. �•,` ��;'°;�, - <br /> EK N XX WP\MACSgr.LE'T <br /> ---------------------- <br />