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FACILITY NAMS:_ST&PN£�S l�CI�uO�i4G� �j <br /> FACILITY <br /> ADDRESS: // L ) . ._ Pin SLE Ll TANK ID 1- -Oar <br /> if -OkM TANK DISPOSITICN TRACKING RECCRD <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 /> SEMCN 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 /> SEMCN 2 --To be filled out by contractor "decontaminating tank(a)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies <br /> by signing� ng below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIUMaRE 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 <br /> Phone <br /> Date Tanks Received Zip <br /> No, of Tanks <br /> AUMCRIZED SIGNAnVE AND TITLE <br /> OLIN' INSTRUCTIONS: Fold in half and staple. Affix <br /> EH N XX Wp proper postage. <br /> \TRACSHT.LET <br />