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SAN J OACt... I N L OCA.L.. HH.A I. _ DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />RR**k*RRFRRRFkRR*R***RRR*RRRFR*RRRfi FRRRR*RRRkFFR*RR*RRF**F**RR*kkRRRRkR**RRRkRFRRRRRRRRRRRR <br />SWrION 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 disposa1,or <br />recycling faculty. The holder of the cermlt with number noted below is responsible for <br />ensuring Chat this form is completed and returned. <br />FACILITY NAME: 60TELLI LIFT TRUCK SERVICE <br />FACILITY ADDRESS: 1856 N. BROADWAY, STOCKTON, CALIFORNIA 95205 <br />TANK ID 139-�,X��/n��1J-- OZ <br />RR**FkRR*RR*i�itMfk�YRkRfi 1�R#*RR*RR*FR****RRR**RfiR**RR***F*Rk*F*F*Rk*Rkk*R**kRRR**kRR*fi**RRRFRR <br />SWrION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: FALCON ENERGY <br />Address: P.O. Box 1257 Zip: 95201 <br />�nrjar)W� 11FORAI T A Phoned (? F,� 71(J$_ <br />Telephone: ( ) Date Tank Removed: <br />SWrION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: FALCON ENERGY <br />Address: P.O. Box 1257 -Zip; 95201 <br />SIQUTON, CALIFORNIA Phonel: IjE3 7jQ2 <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 />IRONMENTAL %AGER <br />SIGNATURE AND TITLE <br />***RRRRRFRRRRRRRRRF*RRR R�R RJ+i RRRRRRRRRRRRRRRRRRRRRRRRR*RRRRkRRkRRRRRkRR*RRkRRRRRRRRRRRRRRRR <br />SECTION 0 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name CAL UOAST TANK <br />Address: 424 IEGNER ROAD Zin, 4Sw <br />Date Tank Received: It//T / q <br />UAIMiORIZED SIGNATURE AND TITLE <br />**RRRRRR**RRRRR*RRFRRRfi*R*****RRRRRRRRRRRRfi RRRfi RRRR*RRRRRRfi kk*************RRR**RR*RR******* <br />Ell 23 019 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 />