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w <br /> FACILITY NAME: _ A� -A/2i ill iUS 7i1/N <br /> FACILITY ADDRESS:3/,3 //. /�7�_�/ 7 �?� TA@#C ID 1 <br /> &Z,73 3 v 9_o y <br /> (1NDER RMO 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 /> a a a a a a a * a t a a a : : • a a a a a a t a a a a a a a t a a a a MOTION 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: XZJ'fi/zr __,-we <br /> Address: (3 3 4i-D,aA7 / .d' <br /> Phone 1 9 UBGo <br /> I' ac� <<rn />e • Zip <br /> Gate Tanks Removed_ Z ?y/ No. of Tanks JU <br /> aaa aa " aa * aaaaaaaaaaaaaaaaa * a * * ataaa �l!�. 1 1989 <br /> SECTION 2 - To be filled out "decontaaLnat �; <br /> by contractor 1[fg tank(s�3 TN <br /> Tank "Decontamination" Contractor�D-�27 Slur rAe <br /> Address_Z/3 3 - AD•ti2f di Phone/_2JL 0860 <br /> /°0 Zip 9s'�nS <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 /> Depaytment of (lealth Services. <br /> �// of t /��/� <br /> SIGNATURE AND TITLE <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 At 7- <br /> Address_1/ J Ra.o o .2 9 Phone# IQ 9 U 3 V <br /> Zip <br /> Date ecelved �.Al No. of Tanks / <br /> AM RIS SIGNATURE AND TITLE <br /> ,.h WAILING INSTRUCTICNS: Fold In half and staple. Affix proper postage. <br /> EH N JO( MP\TRACSHT.LEP <br />