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FACILITY NAME 17F ,457 <br /> FACILITY ADDRESS: TANK ID 1 /19951WI <br /> UNDERGROUND TANK DISPQSITICU TRACKING RECORD <br /> This form Is to 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 /> t t * t * t t * * t * * * * * * * t * t * * * t * * * * * t t t t t t SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: SEMCO INC . <br /> T <br /> Address: 431 Hatch Rd . Phone 1 209-524-9653 <br /> Modesto , CA Zip 95351 <br /> Date Tanks Removed November 23 , No of Tanks 1 - 5n0 Gallon Diesel <br /> --T-ankID #1395-01 <br /> t * * * * ! t t t t >< R * R * # # # # ! t ! * # t t t * R ! t t t ! ! <br /> 38C'PICN 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor SEMCO INC . <br /> Address 431 Hatch Rd . PhoneM209-524-9653 <br /> Modesto , CA Zip 95351 <br /> Authorized representative of contractor certifies by slgning below that tanks) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> De nt gf t Servlw. ��. <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 SEMCO INC . <br /> Address 431 Hatch Rd. Phone/ 209-524-9653 <br /> Modesto, CA Zi 95351 <br /> P <br /> Dat s ReceSrd November 23 , 1988Npf I - 500 Gallon Diesel <br /> . o <br /> AurHORIZED SIGNATURE AND TITLE <br /> t * t * * * * * * t * * * * * t t * * * R t t R * * * t t t t t t * t <br /> NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br /> �;B <br />