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FACILI:"Y NAHE• A�- �� � �1�1F� <br /> FACILITY ADDRESS: 0 � TANK ID I <br /> lrlDE2M=; TANS{ D SPOSITIO�t4TRAaING RECORD <br /> This form is to be returned to San Joaquin Loral 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 /> * # * R # * * * * * # * * * * R * * * # * * * * * * * # * a # * t * * SECTICN 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address Phone I <br /> Zip <br /> [trate Tanks Removed No. of Tanks_ <br /> SECTION 2 - To be filled out by contractor "decontaslnating tank(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 /> SIGNAIME AND TITLE <br /> SEMON 3 - T� be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility (Jame <br /> Address Phonek <br /> r' <br /> Gate Tanks Received ZIP. <br /> of Tanks �Jf <br /> A1IMORIZED SIGMTURE AND TITLE \5�J <br /> MAILING INSTMr-TICtis: Fold in half and staple. Affix proper postage. <br /> Mi N XX WP\TRACSHT.LET <br /> i <br />