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FACILITY NAVE: FiQAA1Z/A <br /> FACILITY ADDRESS: / F R ,TANK ID <br /> LMMGROI.ND TANK D SPOSITIGN TRACKING RECORD Di�EL - /Vpp�j <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 r completed and <br /> returned, <br /> z t ! x Y x t x t x x x * Y x x * x t t z z x ! * z Y Y Y t t * t * * SECTICH 1 - <br /> To be filled out by tank resoval contractor: <br /> Tank Removal Contractor: Semco Inc. <br /> Address: 431 West Hatch Road <br /> Phone k_(209) 524-9653 <br /> Modesto California Zip 95351 <br /> Date Tanks Removed December 2 1988 No. of Tanks 1 <br /> } t * t x * * k x x x * x x * ! * x * x x x * } * * Y ! * * * } x * } <br /> SECTICH 2 - To be filled out by contractor "decontaninatinq tanks)": <br /> Tank "Decontamination" Contractor Semco, Inc. <br /> Address 431 West Hatch Road <br /> Phone/ (209�524_9ti53 <br /> Modesto California Zip 95351 <br /> Authorized representative of contractor certifies by si 1 <br /> has have) been decontaminated in an a below that tanks) <br /> approved maw as may be regulated by <br /> =nt \,qf th Se Tees. <br /> ( I <br /> Richard Hamilton SICNAW AND TITLE Vice-Pres <br /> } * k * ! * t * * } t t t x k x ! * t t k t * * t * t Y Y t Y Y ! 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 Road <br /> PhoneM (209) 524=9653 <br /> Modesto California Zi 95351 <br /> Dates R ce i p�--- <br /> ) � cember 2 1988 No. of Tanks 1 <br /> ichard C. i ton AUTHORIZED SIGNATURE <br /> x x * t z x x x x ! t t * x x * x Y x * * * x k YAND <br /> xT*TLEx xl *e * xe* z <br /> !AILING INSTRUCTIONS: Fold in half and staple. Affix proper postage, <br /> EH N JO( wP\TRACSHT.LET <br />