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FACILITY NAM <br /> ISA FACILITY <br /> FACILITY ADDS: �RyjjTMK IDJ TRACKING RECORD <br /> be returned to San Joaquin Local E{ealth District within 30 days Of <br /> Trus farm is to <br /> - acceptance of tank(s) by disposal or recycling facility. The holder of the petrol. <br /> with number noted above is responsible for ensuring that this forth is completed and <br /> returned. <br /> * * x x * z * * z * z z * z x * x * * z * * x x * * * * x z z * z x * SECTIC4i 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Phone I-- <br /> Address• ------`�- <br /> Zip <br /> Date Tanks Removed No. of. Tanks. <br /> c contractor "decontaminating tanks)": <br /> SECTION 2 - To be filled out by <br /> Tank "Decontamination" Contractor <br /> Address Phonel <br /> Zig <br /> Authorized representative of contractor certifies by signing below that `rank(s) <br /> " manner as may be regulated by <br /> q has(have) been decontaminated in an approved <br /> Department of Health Services. <br /> ------------ <br /> SIGNA•iZ1RE Alp TI`1LE <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 /> Phone#,. <br /> Address ----�� <br /> Zip <br /> Date Tanks Received No. of Tanks— <br /> AUT MIZED SIGRKIiD Ak4u TITLE <br /> WILING INSIRLIGTICHS: Fold in half and staple. Affix proper postage. _ <br /> EH N )CX Wig\TRACSHr.LET <br />