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-�'. SAN .70F>Q" TSI�1 :LOC2�T . 1-I�.A1=,'1I-I D:L S.TFZS CT <br /> UNDERGROUND TAIgK DISPOSITION TRACKING RECORD <br /> SECTION 1 - The San Joaqui,i 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 M�.. <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the r>ermit with nwnber noted below is responsible for <br /> 'ensuring that this form is completed and returned . :�•�• <br /> FACILITY NAME: Kingdon air Park <br /> FACILITY ADDRESS: 12145 N. Devries Road , Lodi , Ca 95242 <br /> .TANK ID #39- - <br /> _ SECTION - 2 - To be filled out by tank removal contractor: ;.qy <br /> Tank Removal Contractor: Western Met rq_� min-�T t iCv <br /> Address. 2735 teepee Drive . Snits Fr___T.nAia_{`A Zip: <br /> Phone# : <br /> Telephone: ( 209 ) 948-6124 [kite Tank Removed: f• <br /> ********X*%*k***********x****'k.*k*k*kAA.I'%%%A'*'A'kAA*A***%kRk*tl'**%*%**#*:l•******k***k*ic********* r� ' <br /> SECPICN 3 -To be filled out by contractor "decontaminating Lank <br /> Tank Decontamination" Contractor : Western Mer c vice In <br /> -Address: 2735 Teepee Dirve Suite E Zip: <br /> Stockton, Ca PhoneN : 209-948-6124' "`-': �� <br /> - i <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 /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, a} <br /> storage, or disposal facility accepting tank . ss <br /> FacilityName. mr, s.,gie r.,6 cai-.Saeramesr>;e - <br /> 3525 52nd Avenue, Sacramento, Ca 95824 . <br /> Address: Zip: y. ; <br /> Phone# : <br /> Date Tank Receivea: <br /> =i <br /> AUTHORIZED SIGNATURE AND TITLE <br /> *********#*****#*****#*%*%]C#%k*:t#**'A'*J:%*%*:t*R'*A•A':Yi'A'A':k'A'*A:tk*i:%i;*%:t*i:*:1%********************* . } !' <br /> EN 23 049 12/88 " <br /> NAILING INSTRUCTIONS: FOLD IN HALT AND STAPLE. hlIrIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKT'ON, CA 95202 <br /> i, <br />