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FACILITY NAME: DOWN RIVER FOREST PRODUCTS FACILITY ADDRESS: 6800 Fairchild Road Stkn. Ca. TANK ID i UNDERGROUND TANK DISPOSITION TRACKING RECORD This form is to be returned to San Joaquin Local Health District within 30 days of acceptance of tank(s) by disposal or recycling facility. The holder of the permit with number noted above is responsible for ensuring that this form is completed and returned. x t x x x x x x x x x x * x x t t x x x x x x x x x t x t t t x x x x SECTION 1 - To be filled out by tank removal contractor: Tank Removal Contractor: Stockton Contracting GRouo, Inc. "> Address: 1000 N. Union Street phone Y (209) 462-5082 Stockton, Ca. Zip 95205 Date Tanks Removed No. of Tanks x t x t x x t t x x x x x x x x x r t x x x x x x x x x x x x x x x x SECTION 2 - To be filled out by contractor "decontaminating tanks)": Tank "Decontamination" Contractor Stockton Contracting Group, Inc. Address 1000 N. Union Street Phone# (209) 462-5082 Stockton, Ca. Zip 95205 Authorized representative of contractor certifies by signing below that tank(s) has(have) been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE x t x x x x x x x x t x t x x t x x s x x x x x x x x t x x t x x t x SECTION 3 - To be filled out and signed by an authorized representative of the treatment, storage, or disposal facility accepting tank(s) . Facility Name Stockton Contracting Group Inc. Address 1000 N. Union Street Phone# (209) 462-5082 Stockton, Ca. Zip 95205 Date Tanks Received No. of Tanks AUTHORIZED SIGNATURE AND TITLE x x x t x x x x x x x t x x x * x x x x x x x x x x x x t x x x t t x l91ILING INSTRUCTIONS: Fold in half and staple. Affix proper poarta EH N XX WP\TRACSHT.LET jo 6 1 89 �ar� s ENVIROPIMENTAL HEALTH PERMIT I SERVICES