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FACILITY NAME: Arn.ft Shy-gL`z- <br /> FACILITY ADDRESS: IR-4d, LBO-MIN (1VI; t�1_Jyl TANK ID t - �Sa4-0I <br /> UNDERGROUND TANK DISPOSITION 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 form Is completed and <br /> returned. <br /> w x x x w x x x x x x w x x x x x x x w x x x x x x x x w w x x x x x SECTION 1 - <br /> To be filled out by tank renxmal contractor: <br /> T rsk Removal Contractor: J i M <br /> Address 3S/ I!/!g>r Ai✓ /��_Phone I�-�T-1(017S- <br /> "D <br /> -/_0 _zip �'S2-iO <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaainating tank(s)": <br /> Tank "Decontamination" Contractor �Si rvi `7Ai n2p�- 0.1-1 Z^LL <br /> Address 35% Al. IS ecfkln4 r✓ /(�q( Phone# v Yml7J <br /> 4-4 D. 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 /> Departure 11<h Series. I/ <br /> SIGNATURE AND TITLE <br /> t <br /> /* <br /> SECTION <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 sCHNIiynn (S � <br /> RANCHO CO- <br /> Address— <br /> O Address 9SG- Phone# <br /> Zip !AN 13 9999 <br /> Date Tanks Received RIP No. of Tanks r -,NMENTAL HEALTH <br /> L- A -_?iv11T I SERVICES <br /> L <br /> AUTHORIZED SIGNATtMAND TITLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />