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SAN .j c)2b6- J I N LOCAL HEAT -r e l Ix I S TR I CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />******************************************************************************************* <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 responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: Breun W s <br />FACILITY ADDRESS: 7676 Pacific Ave. Stockton <br />TANK ID 039 - <br />SECTION <br />39 -SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Trumpp Bros. Inc. General Engineering Const. <br />Address: 1540 Industrial Ave. San Jose Zip: 95112 <br />Phone#: 408-292-1201 <br />Telephone: ( `D ) ;� "I 2 G Date Tank Removed: <br />******************************************************************************************* <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: Zip: <br />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 />SIGNATURE AND TITLE <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility <br />%accepting tank. <br />Facility Name I � �' 7-/ .2: , -5—C, L- CG , <br />Address: 1)� �Z 0 C 117, ill)- /ii�S�, <br />Date Tank Received: <br />_Zip: /6 <br /># : his' s-- 2S 5 - <br />AUTHORIZED SIGNATURE AND TITLE <br />******************************************************************************************* <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 />