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FACILITY HAM: Port of Stockton Foods Dist . Inc . <br /> FACILITY ADDRESS: 1950 E . Miner TANK ID I <br /> UdDERGROU(D TANK DISPOSITION <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 /> x ! x * * t ! x x * * x * t x * t t t * x r * ! x * t t ! x ! x t ! x SECTION 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Oil Equipment Service <br /> Address: PO Box 950 phone 209-754- 1808 <br /> San Andreas , CA Zip 95249 <br /> Date Tanks Removed No. of Tanks 1 <br /> x t x ! ! x t t * x * t x * ■ * x x ! x * x * * x ! x t * * ! t ! * ! <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor N c r C a l O i l Co . <br /> Address PO Box 645 Phone# 800-332-8710 <br /> Denair , CA Zip 95316 <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 /> t t x * x * x ! x * ! * * ! * * * x * # x ! * x ! x ! x x ! x x ! t x <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 Triangle Inc . of Sacramento <br /> Address 3525 - 52nd Ave phone# 916-421 -1990 <br /> Sacramento , CA Zip 95823 <br /> Date Tanks Received No. of Tanks <br /> AVPHORIZED SIGNATURE AND TITLE <br /> t * * # * * t t * * x * x t t ! t t x * t * ! ! x t ! * Y t * * ! x * <br /> f NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N )OC WP\TRACSHT.LET <br />