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FACILITY !i�'►t�: ��1ti��.��-- K_� ,_�f�-- - -,,,., - - - <br /> FACILITY ADDRESS:2Y� TANK ID <br /> UMERGROUND TAMC DISPOSITION TRMXIHG REOORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> aoceptarxx of tank(s) by disposal ar recycling facility. The holder of the permit <br /> with number noted above 1z respon3lblc for ensuring that this form is completed and <br /> returned. <br /> - <br /> 1 To be filled out by tank rcaoval contractor: <br /> Tank Removal Contractor: - <br /> Addreas: 4) rte-SCS hone <br /> y o Zi <br /> Date Tanks Removed �7'--�p. iio. of Tanks r <br /> MMON 2 - To be filled out by contractor Rdcoontaminating taz*(a)*: <br /> Tank "gecontamination" Contractor <br /> Address ehonCr?,�f <br /> 1` ---"A a zip <br /> Authorized representative of contractor cGrtiflas by signing below that tank(s) <br /> has(have) been decontaminated in an approved wanryer as way be regulated by <br /> Hepar nt of Health Service. <br /> SIGH&IWI AND Tlids <br /> * ! * s <br /> i :ECTION 3 - To be filled out, and aigned by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(%). <br /> Facility Name_( • ._._ <br /> Address � � �� Phenol O�A� <br /> Zip <br /> ' Gate Tarns Rec l No. of Tan --2 ,,,,�„ <br /> if <br /> 1 AiJi MIZED SIGNATUIE AND TITLE <br /> s : * * * * s * * * : * * : * * * <br /> MILING INSIR TCW; Fold in half and staple. Affix proper postage. <br />