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FACILITY NAME: Po C- 6 0,o <br /> FACILITY ADDRESS: I I C7 S T-16c Ar�hyrTANK ID # 39 - 2328' -ODU I <br /> UNDERGROUND TANK DISPOSITIONRAIXING 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 * * k x * x * * * * * * x * * * * * * SECTION 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 /> L <br /> SECTION 2 - To be fllled 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 /> 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 /> Zip <br /> Date Tanks Received No. of Tanks <br /> AUITMIZED SIGNATURE AND TITLE <br /> !AILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSffr.LET <br />