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FACILITY NAHE• CALIFORNIA DEPARTMENT OF TRANSPORTATION <br /> FACILITY ADDRESS: 2125 S. Lincoln St. , Stockton TAW ID I <br /> UMERGROWD TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> aoceptanoe 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 /> c <br /> SECTIDd 1 - <br /> To be filled out by tank reaoval contractor: <br /> Tank Removal Contractor: SEMCO, INC. <br /> Address: 431 ,W. Hatch Rd. pace 1 (209) 524-9653 <br /> Modesto, CA P <br /> Zi 953 -- <br /> Date Tanks Removed 3-14-89 i(p, of Tanks <br /> s R t R R R t t f f !• t R R t R t t t : x R R t R Y f t t t : t t ! t <br /> SECTION 2 <br /> - To be filled out by contractor "decontaalnatirg tank(a)•: <br /> Tank "Decontamination" Contractor SEMCO, INC. <br /> Address 431 W. Hatch Rd. Phonel (209) —524---9673 <br /> Modesto, CAZip 95351 <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved mariner as may be regulated by <br /> De nt of Health Servi <br /> SIGNATWZ AND TI <br /> t ! t R R t t t f t ! x f ! ■ ! It t t ! t t t Y t t f f R R t t t t t <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal faculty accepting tank(s). <br /> Facility Name SEMCO, INC. <br /> Address 431 W. Hatch Rd. l (209) 524-9653 <br /> Modesto, CAZip 95351 <br /> Da s Recei 3-14-89 No. of Tanks I <br /> J •. <br /> ALnIMIZED SIGUhnitt AND TITLE <br /> t R t t t ! ! R f R f t R t t t t t t t ! t f R t R R t t t t t t t t <br /> SLING INSIR Y-MCHS: Fold in half and staple. Affix proper <br /> EH N XX HP\TRACSHT.LET ,,P <br /> MAR 8 1989 <br /> ENVIRONMENTAL HEALTH <br /> PERM MSERVICEq <br />