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' t <br /> FACILITY NAME: Port of Stockton Foods' Dist . Inc . <br /> FACILITY ADDRESS: 2001 Fremont TANK ID t —I <br /> LNDFRGRO(AND TANK DISPOSITION j%W <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 /> 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 /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor NorCal oil Co . <br /> Address PO Box 645 phonel 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 mariner as may be regulated by <br /> Department of Health Services. <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 Triangle Inc . of Sacramento <br /> Address 3525 - 52nd Ave phi 916-421 - 1990 <br /> Sacramento , CA Zip 95823 <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> tw i NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EN N M WP\TRACSHT.LET <br />