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r <br /> FACILITY &40: <br /> FACILITY ADDRESS: [SIL g�yQ3 <br /> ID <br /> LtMMGROUND TAMC DISPOSITION TRACXING <br /> This form is to be RDGOftD <br /> returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or re <br /> with n recycling facility. The holder of the <br /> umber noted above permitis responsible for ensuring ng that this form is completed and <br /> # # # # # * # * # # # # # # # * * # # # # * # # # # # # # # # # * * # Ste. <br /> To be filled out by t� r ION 1 -- <br /> removal contractor: . <br /> Tank Removal Contractor: <br /> Address: <br /> Phone 1 <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> RECTICH 2 - To be filled out <br /> by contractor decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address <br /> Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signs b <br />� has(have)hhas(have) been decontaminated in signing that tank(s) <br /> an approved manner as may be regulated by <br /> DePartment of Health Services. <br /> SIGNATLRE AND TITLE <br /> 'EMION 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 <br /> PhoneM <br /> Zip <br /> Date Tanks Received <br /> No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> MAILING I&%ML iTCNS: Fold in half and staple. Affix <br /> EH N XX WP\TP-kMHT.LET Proper Postage. <br />