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FACILITY NAME: COLLINS ELECTRIC COMPANY <br /> FACILITY ADDRESS: 611 W. Fremont Street Stkn. TANK ID i <br /> UNDERGROUND TANK DISPOSITION 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 * * * * * z t t w * * * * t t t * * z ! SE=CN 1 _ <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: STOCKTON CONTRACTING GROUP. INC. <br /> Address: 1000 N. Union Street phone t (209) 462-1481 <br /> Stockton, Ca. Zip 95205 <br /> Date Tanks Removed No. of Tanks 2 <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor Stockton Contracting Group. Inc. <br /> Addre83 1000 N. Union Street phoney (209) 462-1481 <br /> Stockton, Ca. Zip 95205 <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 /> SIGNATURE AND TITLE <br /> SECTION 3 - To be filled out :nd.-;i-fined b an authorized representative of the <br /> treatment, storage, or disposal ac accepnq tan�i7sT <br /> Facili�.Name— trading Group Frtr-- - — <br /> Address 1000 N. Union Street phoney (209) 462-1481 <br /> Stockton, Ca. Zip 95205 <br /> til <br /> Date Tanks Received No. of Tanks 2 <br /> XLAUTHORI7.ED SIGNATURE AND TITLE <br /> (Xl� MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br /> OTT <br /> - - <br /> _, <br />