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FACILITY NAME: a5rxr mil/ <br />FACILITY ADDRESS:/S1131�In/���jj�����/��l1��1t TANK ID M _ <br />UNDERGROUND TANK DISP0SCCITI�C#7"lJ ING 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 />* * t k t x t k x * t * * * * * * x x x * * * * * * * * * * * * * * * SECTION 1 - <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: Phone # <br />Zip <br />Date Tanks Removed No. of Tanks <br />k* x x** x x k* k k** x k*** x** k x t* k k t x t t x x* <br />f <br />SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br />Tank "Decontamination" Contractor <br />Address Phone# <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 />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 <br />Address Phnr * <br />Date Tanks Received No. of Tanks <br />AUTHORIZED SIGNATURE AND TITLE <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N XX WP\TRACSHT.LET <br />