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FACILITY NAN -"�QAAI � <br /> FACILITY ADDRESS. I <br /> R TANK ID #_J! c* Ds- <br /> u�DPRGRKx1ND TANK D SPOSITICU TRACKING RECORD <br /> This form 1s to be returned to San Joa9in Local Health <br /> District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The <br /> with n holder of the permit <br /> returned,tuber noted above is responsible for r ensuring that this form rIs completed and <br /> x t * t ! t x SECTION 1 - <br /> Tb be filled out by tank removal contractor: <br /> Tank Removal Contractor: Semco Inc. <br /> Address' 421 ri ct u <br /> trh Rn Phone 1 <br /> M --L2D3-1--L2,4-9653 <br /> — p-stc California ZiP 95351 <br /> Date Tanks Removed December 2 1988 <br /> t t x x x x ! k x x t * x x No. of Tanks 1 <br /> SECII(lPl 2 - To be filled out by contractor "decontaminating tank(a) <br /> Tank "Decontamination" Contractor Semco Inc. <br /> Address 431 West Hatch Road <br /> Phonel <br /> �'1r�Pstn ('aliforni -- <br /> AuZip 95351 <br /> zed representative ofonractor <br /> certifies b <br /> has(have) been decontaminated in an approved manner <br /> signing below that tank(s) <br /> toren anner as may be regulated by <br /> $ ices. <br /> Richard C. Hamilton SIaNAMZE AND TITLE Vice-Pres <br /> t t k k t x t t t t t t ! k k t ! ! t ! ! ! t ! k * t t ! t t t t t k <br /> SECTIO <br /> treatment, <br /> 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal <br /> Facility Name facility accepting tank(s) . <br /> Se <br /> Inc. <br /> Address- 431, West Hatch Road <br /> PhoneM (209) 52.4-9653 <br /> Modesto California Zip 95351 <br /> Date cs Racei b cember 2 lggg <br /> �\ /ll No. of Tanks 1 <br /> Richard C. Hamilton AUMIRIZE SI(-NA <br /> TIRE AND TITLE Vice-Pres <br /> ►AILING INSTRL)MOKS: Fold in half and staple. Affix proper postage <br /> Eli N XX WP\MACSHT.LET <br />