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3• �„ <br /> SAN J0AQL3SN LOCAL HE_Ar.TH D2STRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> xxxzzzzxxzxzxxxzxzxxxzzxxzxxxxxxzxxzzxzzzzxz*z********zXx**x*****xx**x***xx**zxzzzzxxxxzzzx <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed with its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> i <br /> FACILITY NAME: Kooyman Trucking, Inc. <br /> FACILITY ADDRESS: 1340 West Charter Way Stockton, California 95205 <br /> TANK ID #39-_ - <br /> *x*z***x******xxzzzxzzzzxzxzz zxzzzzxzxzzzxxzz***x***z**z*x***x*****x**z*z*xzzzzzzxxxzxzzzz <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor:_ _Telic Engineering Corporation <br /> Address: P. 0. Box 2076 Zip: 95201 <br /> Stockton, California Phone#: 209 465-2000 <br /> Telephone: ( ) Date Tank Removed: <br /> zxxzzzxzxzzzzxxxxxzzxxzxzxzxxxzzzxxzxxxxzzzzxzzxzzz**x*xx*xxx***********z**x**zzzzzzzzzzxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Telic Engineering Corporation <br /> Address: P. 0. Box 2076 Zip: 95201 <br /> Stockton California Phone#: 209 465-2000 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> xzxzzxxzxzzxxxxxxxxxzxxxxxzxxxxxzzzxzxxzzzzzzzzzzzzxz****xx*zz*X*h**xx**x*x*xxxxzxzzzzzzxxx <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name Terry Perkins <br /> Address: 9740 West Dos Palos <br /> Firebaugh, California Zip: <br /> Phone#: 209 659-2501 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> zxzxzxxzzxzxzxxxxxxxxzzxxxxzxxxzzxxzzxzxxxxxxzzzxxzx*z*zzz*k*z********x**x***xzzxxzxxzxxxzx <br /> Ell 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PR0PER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />