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FACILITY NAME: DOWN RIVER FOREST PRODUCTS <br /> FACILITY ADDRESS: 1221 N. Golden Gate Ave. TANK ID Y <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> x t z x x x t t t t t x x x x z z x x x x x t z z z t x t t z t t z t SECTION 1 _ <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: STOCKTON CONTRACTING GROUP. INC. <br /> s Address. 1000 N. Union Street phone 1 (209) 462-5082 <br /> Stockton, Ca. Zip 95205 <br /> Date Tanks Removed No. of Tanks <br /> SECTION 2 - To be filled out by contractor "decontaminating tank(s)": <br /> Tank "Decontamination" Contractor Stockton Contracting Group, Inc. <br /> Address 1000 N. Union Street phonel (209) 462-5082 <br /> Stockton, Ca. Zip 95205 <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s) . <br /> Facility Name STOCKTON CONTRACTING GROUP, INC. <br /> Address 1000 N. Union Street phone# (209) 462-5082 <br /> Stockton, Ca. Zip 95205 <br /> Date Tanks Received No. of Tanks <br /> AUTHORIZED SIGNATURE AND TITLE <br /> NAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />