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FACILITYC NAME: ro / ! Rd (/ TAW <br /> FACILITY ADDRESS: 393 / /V"i�em R TAMC IDM <br /> UNDERGROUND TAMC DISPOSITION TRACKING RECORD <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 /> x x * * x x * x * x * * x * * * * * x x x * x x t * * x * * * x * * x SECPI OM1 1 <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> ' er- c <br /> Address: T�� /� ! ( k /p\ 2/. Phone M oQ6 Jra ��oJ 3 <br /> Zip X53 5J <br /> Date Tanks Removed No. of Tanks/ <br /> / 7o3 -.L <br /> SECTION 2 - To be filled out by contractor "decontamina' ing tank(s)": <br /> Tank "Decontamination" Con�tractor <br /> Address ,A \ UV , T�i�7 C lc� PhoneM <br /> VYI�" E \xi O 1 Zip <br /> Authorized representative of contractor certifies by signing belov that tank(s) <br /> has ve) been decontaminated in an approved mariner as may be regulated by <br /> Dei nt of s <br /> Halt erviqe � <br /> V es �- <br /> SIGNATUZE AND TITLE <br /> i <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 Na Z 0,� �} <br /> Address Iris Phone#�—� -_/ � -- <br /> �M�; zip 91-'> <br /> D& T*ks �� �' No. of Tanks <br /> !YV1y R� - <br /> AUTHORIZED SIGNATURE AND TITLE <br /> x x t x x x x t * * * x * t x * t x x x x t t x t x x * x t x * x x x <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />