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' ---Y&- LITY NAME: iO <br /> Qn� !I tilrr�Y <br /> FACILITY ADDRESS: F p���_ <br /> R TANK ID s js4 "i <br /> L*0�11(ROIXID TANK D SPOSITION TRACKING RMM <br /> This form is to be returned to San Joa in �A7 2 300 <br /> acceptance of Local Health District within 30 days of <br /> with n noted <br /> by disposal or recycling facility. The holder of the permit <br /> umber no above is responsible for ensuring that this <br /> returned, form is completed and <br /> t x * * t * * ! * * * t * <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor Semco Inc. <br /> Address: Hest Hatch <br /> _Road <br /> Modesto California _Phone i 4!2aa`--52A-9653 <br /> Date Tanks Removed Z1P 921 <br /> of Tanks 1 <br /> * t t * * * k ! * * * V ! t 1t t ! t ! x ! t t ! x R ! t x x <br /> S8CN 2 - To be filled out " <br /> by contractor decontaminating tank(a)": <br /> Tank "Decontamination" Contractor Semco Inc. <br /> Address_ l W Qt Hatch <br /> Roan PhoneM (2091 524-9.53_ _ I <br /> _ Iodesto California <br /> Authorized representative of Zip 95� � <br /> contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved <br /> #1c <br /> nt of )imfr as may be regulated byIt Seryd C, Hamilton , <br /> * * ! * * x x • k x ! t * * t $IK�(ATZ ?E AND TITLE Vice-Pres <br /> * t ! * ! * * t t t * t k k k t t ! R * <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 /> PhoneN (209`4_9653 <br /> Modesto, California <br /> t Zip 95351 <br /> s e �c r 2, 1988 -- <br /> No, of Tanks 1 <br /> Richard C. Hamilton AI1IflORI SIGNATlRE AND TITLE <br /> * * * * * * * * k k * * * * * * t t * Vice-Pres <br /> HAILING I�RIILTICNSt t k k k x k * * * * * * t * x <br /> : Fold in half and staple. <br /> EH N XX WP\ Affix proper Postage. <br /> TRACSNT.LET <br />