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FACILITY NAME — <br /> FACILITY ADDRESS: 3 W TANK ID # �3 9— (J <br /> tuDERCYtOM 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 /> x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br />>? <br /> Address: Phone # <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <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 /> SE7CTION 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 /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> !AILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N )OC WP\TRACSHT.LET <br />