Laserfiche WebLink
FACILITY NAME: LONE t-, EE VINYARDS <br />FACILITY ADDRESS: 9691 Murphy, Stockton, CA TANK ID <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 />* * * * x x * x * X * * * * * * * t t * * * x * * * * * * * * * * * * SECTION 1 - <br />To be filled out by tank removal contractor: <br />Tank Removal Contractor: SEMCO, INC. <br />Address. 431 West Hatch RD. Phone 1 524-9653 <br />Modesto, CA Zip 95351 <br />Date Tanks Removed 12-29-88 No. of Tanks <br />i <br />SECPICN'2 - To be filled out by contractor "decontaminating tank(s)": <br />Tank "Decontamination" Contractor SEMCO, INC. <br />Address 431 West Hatch Rd. Phone#524-9653 <br />Modesto, CA „ _ 95351 <br />FEB 1 9989 V <br />N\111RONM,N'TAL HEALTH <br />PERMIT / SERVICES <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 <br />/Services. 4�_// <br />d, 6 �c <br />SIGNATURE AND TITLE <br />R t* t t* t**** t t t* t***** R t* t R x** 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 facility accepting tank(s). <br />Facility Name SEMCO, INC. <br />Address 431 West Hatch RD. Phone# 524-9653 <br />Modesto, CA Zip 95351 <br />Date Tanks Received 12-29 No. of Tanks 2 <br />AUTHORIZED SIGNATURE AND TITLE <br />R k R R R R R t x* t x x t■■* t* t R R X R*** x t* t t t t t <br />MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br />EH N XX WP\TRACS[rr.LET <br />1 <br />