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Fe fPA-e'cr—�-c I2FAU—ry <br /> FACILITY NAME: .P P _ <br /> FACILITY ADDRESS: �C +0 /J (S�y <br /> ( /S— ' G'✓E�F <br /> f . TAW ID /_� <br /> Thisform is to LNDERGROUNO TAIL( DISPOSITION TRA(XING RECORD <br /> be returned to San Joaquin Local Health District within 30 days of <br /> acCeptance of tank(s) by disposal or recycling facility. <br /> with number noted above Is res The holder of the <br /> responsible for ensuring Permit <br /> returned, n9 that this form is c <br /> X x omple <br /> X x ted and <br /> X X x X x x X ■ : t X X : x x k t X x x : : k x x k x : x x x - <br /> To be filled out by tank removal S�.I,I� 1 <br /> tractor: <br /> Tank Removal Contractor: <br /> VTAddress: <br /> Phone <br /> Date Tanks Removed Zip <br /> No, of Tanks <br /> SE <br /> X * x 2 X x x x x x x x x rx x x x x x x X x X x x x x x x x x * x x <br /> SECTION - To be filled out by contractor "decontaminating <br /> Tank "Decontamination" Contractor tanks)": <br /> Address <br /> Phone# <br /> Authorized representativeof contractor Zip <br /> has(have) been decontaminatedcertifies by signing below that <br /> Department of Health Services. tank(s) <br /> in an approved manner as may be regulated by <br /> SIGNAI[.RE AND TITLE <br /> k k x X k k IF x X k t x x X k ■ X t X k t x k X k k t k k ! k x X x x <br /> S�ttmeent' storae filled out and signed by an authorized representative of the <br /> 9e, or disposal fa <br /> Facility Name cility accepting tanks) <br /> Address <br /> PhaneM <br /> Date Tanks Received Zip <br /> No. of Tanks <br /> A[71TiURIZED SICNATURE ANDTITLE <br /> MAILING INSTRUCTIONS:X x x x x x x x x x x x x x X x x x x x X k x x * * k x x <br /> Fold in half and staple, Affix Proper <br /> Postage. <br /> EH N XX WP\TRACSHT.LEI <br /> .4.ti+ <br />