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RM"I. • <br /> FACILITY NAME: `¢ <br /> FACILITY ADDRESS: as 1 4R o I 1 Lg l e TANK ID3r <br /> UVDfRGROW 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 /> * * * * * * * * t * * * * * SECTION 1 - <br /> To be filled out by tank reaoval contractor: <br /> Tank Removal Contractor:_ /11 p r �;{ �t}�n�'.t r <br /> h` Address: C Phone I <br /> Zip_ 9 �� <br /> Date Tanks Removed No. of Tanks_ <br /> SECTION 2 - To be filled out <br /> by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phonel <br /> Zip <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 Phone# <br /> I <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUnMIZED SIGNATURE AND TITLE <br /> * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * <br /> HAILING INSTRUCTIONS: Fold in half and staple. Affix <br /> Proper Postage. <br /> EH N XX WP\TRACSHT.LET <br /> f. <br />