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�../ ./ <br /> FACILITY NAME: — <br /> FACILITY ADDRESS: TAMC ID 4 ��23 -cel <br /> CAlDERG MM TANK DIMWITICN TRACKING RDOMD <br /> This form is to be returned to San Joaquin Local Health District vithin 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> vith number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> SECrqCK 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: r .}/,iris 1i✓G , D �L�to l�l' <br /> Gr'? Address: Ela a , 'i.-•r':47 %'. Phone I Via' =' 0 V <br /> Zip n 1989 <br /> Date Tanks Removed <br /> _—' 7_----��( � 9 — +Eanlri!S-Rv!CES <br /> No. of Tanks � ,C�sv"' is crr, 1 a TH <br /> � <br /> SELTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor_. <br /> Address-3/3 3 - /J D-/ 2 f Phone M %3 I -= 4 <br /> Zip. <br /> Authorized representative of contractor certifies by signing belov that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Depak/ ent of�ealth grvices. <br /> j JIC�vymIO<' <br /> SIGNAIME 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 Name7-AWr <br /> Address_ iPa a o J ? Phone I I C)'7 <br /> Zip_ <br /> Date eceived a f' No. of Tanks / <br /> ALUUMIZSA SIGNATURE AND TITLE <br /> NAILING IHS RUCTIONS: Fold in half and staple. Affix proper postage. <br /> ER N XX MP\TRACSNT.LET <br />