Laserfiche WebLink
10,000 gallon unleaded <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> z x x x z z z x x x * x * x * x x z x x x z * x * * * * x x x x x x z <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: Mid Cal Tractor <br /> FACILITY ADDRESS: 1120 W. Charter Way, Stockton TANK ID <br /> z x x x x x x x x x z x z x * z x x x x x x x z z x * x x z z * x * <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Petro-Check, Inc. <br /> Address: 2076 Acoma Street Phone # 916-927-8155 <br /> Sacramento, CA Zip 95815 <br /> Date Tank Removed <br /> x x z z z x z z z z * x x x z * z z x x x x x z x x x z z x * x x x z <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor Petro-Check, Inc. <br /> Address 2076 Acoma Street Phone# 916-927-8155 <br /> Sacramento, CA Zip 981, <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> z x x x x x x x x x x x x x x x x x z z x x z x * z z * x x x z z * z <br /> SECTION 4 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. C, qt�-(,c,`PI iu S <br /> Facility Name Refinery Services, Inc. <br /> Address 13331 North Highway 33 Phone# 800-874-4444/209-892-6742 <br /> Patterson, CA Zip 95363 <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> x x x z z * x x x z z * * z * x x x z x x x x x x x x * * * * x * * * <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P.O. BOX 2009 <br /> STOCKTON, CA 95201 <br />