Laserfiche WebLink
L <br /> SAN a0AQLJI N LOCA%6� HEAT•TH DI S71RI CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> k*************kXXkX**k***k*XX****X**k**X**X*k*X*******k****XX*****X*kk*kk**k*********kk***X <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 /> FACILITY NAME: UNOCAL BUTK PLANT 907RR <br /> FACILITY ADDRESS: 8203 W. Business Loop 205, Tracy, CA. 95378 <br /> TANK ID 139- - <br /> kXXX**kkkXX**k**kkk*******k**XX*****XX***XX*kk*XX***XkXX*k*k**XXX*XX**Y**k*X**XXXXX*X*X**Xk <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: BASSETT CONSTRUCTION INC. <br /> Address: 7730 Greenridge Way Zip: 95628 <br /> PAJ , n,i- Q,, i€gi_n: a - PhoneM: 424 <br /> Telephone: ( 916 ) 967-7424 Date Tank Removed: <br /> *XXX**k*kX*kk**X*X*Xkk*X*kkXXXXY*kX***Xk******X*kXX*Xk*kXX**X*kkX*kX*****X*k*kkXXkX*kkXXX*k <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: PLACER TRACTOR SERVICE <br /> Address: 7200 Wells Avenue rnnmic rA _Zip: 95650 <br /> PhoneM: <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 /> k***kXXX*kkX*XX*k*XX**X**k**k***k**X***X***X*****kX******k***X*k*****XXX**XXkkk*k****Xkkk*k <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name ERICKSON INC . <br /> Address: 255 Parr Boulevard Richmond CA. 94801 Zip: <br /> PhoneM: ( 4151 R5-i�3 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ***X*k*****X*XX**X*k**X**k**X**k**X**********X**X********X*****X*Y**kk*****X****Xkk***kkX*X <br /> Ell 13 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> p. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />