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SZLW JOA JI N LOOP. HF:A T •TI DI STM CT Z <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> x*****x***************************z***xkkkkxxk*x*xxxxx**kxxkx*kkx********************kx**** <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 re able for <br /> wring that this form is completed and returned, <br /> FACILITY NAME: COLLINS ELECTRIC COMPANY <br /> FACILITY ADDRESS: 611 W. Fremont Street <br /> TANK ID #39- - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: STOCKTON CONTRACTING GROUP, INC. <br /> Address: 1000 N. Union Street Stkn. Ca. Zip: 95205 <br /> Phone#: <br /> Telephone: ( 209 ) 462-5082 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: STOCKTON CONTRACTING GROUP, INC. <br /> Address: 1000 N. Union Street Stockton Ca Zip: 95205 <br /> Phone#: (209 462-5082 <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 /> kx**x*x***k****xkx***xx***x******x**k***k****kx***k*kxk**k******k***kk**k****xX*k*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 Stockton Contracting Group, Inc. <br /> Address: 1000 N. Union Street Stkn. Ca. Zip: 95205 <br /> phone#: (209) 462-5082 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> **zz***kzzx*zzzz***zz*x**xz**zzx**z*zzx**z*x**z*k****zzx***zxzz*x**zz*z*z*kzzx***zzzzx*zzxz <br /> EH 23 049 12/88 <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 />