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.1 <br /> FACILITY NAME: <br /> FACILITY ADwms: ID 2 <br /> UNDERGROUND TANK ,DISPOSITION TRA(XING RECORD <br /> This form is .,to be returned-to San Joaquin Local Health District within 30 days of <br /> aeeeptance .ot tank(s) by disposal orrecycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> SECTION I <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 /> SECTION 2 To be filled out by contractor "decontaminating tank(s)": <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 /> SIGUATURE 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 /> AC THMI ZED SIGNATURE AND TITLE <br /> MAILING INSTRUMONS: Fold in half and staple.: Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br /> ti <br /> i v _ <br />