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SAN .70AC�1IN LOCA" Ar.TI� DISTRICT <br />LNDERGROLIND TANK DISPOSITION TRACKING RECORD <br />***R***RfifR#RRRRRR*R**R****RXX#*Rf RRRR***R*RRRR**R*RRRR*fi**#RXR**RBBB*RR*RRRRR*RR►RRRffRRRR <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 g&rmlt with numb noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME:_ UOTELLI LIFT TRUCK SERVICE <br />FACILITY ADDRESS: 1856 N. BROADWAY, STOCKTON, CALIFORNIA 95205 <br />TANK ID 139- D <br />***#**#**####*# #*******RR*RRR*R*}}}RRR*#RRR**RRR**}*RR*RRX*#*##*###***RR******RR****RRR*** <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: FALCON ENERGY <br />Address, P.O. Box 1257 Zip: 95201 <br />IRnRNIA Phone/: <br />Telephone: ( ) Date Tank Removed: <br />RRR*RRR#RX**R**R*RRRRR*R*X***RRR*RRRR***RRR*RRRR*RRR*RRRRRfi******RRR**X*RR*****RRRRR*****fR <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: FALCON ENERGY <br />Address: P.O. Box 1257 Zip; 95201 <br />SIUCKTON, CALIFORNIA Phone #. <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 />IV V.P. & En <br />RONMENTAL MANAGER <br />SIGNATURE AND TITLE <br />**RRRRR#***R*RRRRRR*RRR` *RR** Rfi RRRRRRRRRRMRR**R*RR**R**RRkR*k**Rfi *X*Rfi R*RRfi *RRR*Rf *RRRRR*Rfi <br />SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name <br />Address: 424 IEGNER ROAD Zip: 95380 <br />URI OCK. LAI 1FORNIA Phonel: (20T BN qM6 <br />Date Ta jq <br />AUTHORIZED SICZ4ATURE AND TITLE <br />Ell 23 019 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 />STocxTON, CA 95202 <br />