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i <br /> F { <br /> FACILITY NAME: - <br /> v� L516F/ a <br /> FACILITY ADDRESS: L1,iD& TANK ID I JJ /(O(0 6� <br /> ��._. <br /> UNDERGROUND TALC DISPOSITION TRACKING RECORD <br /> } This form is to be returned San Joaquin Local Health District Within 30 days of <br /> t , <br /> acts of tank(s)- by disposal 3 <br /> acceptance poral or recycling facility. The holder of the permit <br /> With number noted above is responsible for ensuring that this form 1s completed and <br /> returned. <br /> * * * * SECTION 1 t <br /> To be filled but by tank removal contractor: <br /> Tank Removal Contractor: <br /> k Address: Phone N <br /> Zip <br /> $ <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor <br /> AddressPhonel <br /> 3Zip <br /> Authorixed,� representative of contractor certifies by signing below that tanks) <br /> has(have) been decontaminated'in an approved mariner 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 /> u <br /> Address Phone# <br /> Zip <br /> Date TanksiReceived No. of Tanks <br /> Au' imiZED SIGNATURE AND TITLE <br /> tMULING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br /> s <br /> a <br />