Laserfiche WebLink
FACILITY NAME: s. <br /> FACILITY.:ADDRESS: IC ID # 3c-i&�O _`Q r. <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form isto 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 /> To be filled �out. by tank removal- contractor: <br /> Tank Removal Contractor: <br /> 3 <br /> Address: Phone I <br /> Zip _ <br /> . Date1Tanks Removed No. of Tanks <br /> s9CI'ION 2 - To be filled-out by contractor. "decontaminating tanks) <br /> Tank "Decontamination" Contractor. <br /> Address }° Phone# <br /> } F. Zip <br /> Authorized representative of-contractor certifies by signing below that.;tank(s) <br /> has(have)lbeen,decontaminated. in an in <br /> approved manner as may be regulated`by <br /> Department of Health Services. . <br /> :SIGNATURE AND TITLE _ <br /> $ SELTION 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 /> MAILING INSTRUCTIONS: Fold in half and'staple. Affix proper postage. <br /> EH N-XX WP\TRACSHT.LET <br />