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FACILITY NAHE:_ UZZL CIN TRrnTr_ <br /> FACILITY ADDRESS:74 n3 Na vv nr c <br /> TAMC ID 1 <br /> 'JMERCROUND TAM( DISPWITION TRMXING REOORD <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 <br /> with number noted above is responsible for ensuring that this form Is cothe permit <br /> the <br /> and <br /> returned, <br /> t R t t f R R t 4 <br /> To be filled out by tank removal contractor: SECTICN 1 <br /> Tank Removal Contractor: SEMCO, INC. <br /> Address:_ 431 West Hatch Rd <br /> Phone 1_(20— a 5UA-9653 <br /> Modesto CA <br /> Zip 95351 <br /> Date Tanks Removed 9-26-86 No. of Tanks <br /> R t R t R Y R R f t tt Y t ! R f t t R R ! R ! t R t t R R Ry t <br /> -%LHON 2 - To be filled out by contractor ■decontaminating tanks)": <br /> Tank "Decontamination" Contractor SEMCO INC. <br /> Address 431 West Hatch Rd . <br /> Phonel (209) 524-9653 <br /> Modesto, CA' ----- <br /> Authorized representative Zip 95351 <br /> has(have) been decontaminateto contractor certifies by signing below that tanks) <br /> d Sn an approved manner as may be regulated by <br /> Depa tment of Health Services, <br /> �1l � i` t r �� <br /> 3IGNATU E AND TITLE <br /> ■ t t t t t t ! R ! R R t Y t t R t R ! t R R f ! R R R t Rt Y 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(e). <br /> Facility Name SEMCO, INC. <br /> Address 431 West Hatch Rd. <br /> Modesto, CA Phone/ (209 ) 524-9653 <br /> Zip 9535 1 <br /> Date, Tanks Rec&Ived 9-26-86 No. of ,ranks 1 <br /> Ai►i7iCYtIZED SIGKA7tGE AND TITLE <br /> R R R R R Y t R t t t t t t t t ! f t t R R t R Y R R R t t Y R t t Y <br /> MAILING IHSTRUCITDNS: Fold in half and staple. Affix proper postage, <br /> EH N XX NP\TRACSHT.LET <br />