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0 <br />.SAN .JC _QLJI N L.C7CAI HEALTH IDIS TFt I CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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 pgrmit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: CHANNEL MECHANICAL <br />FACILITY ADDRESS: 1725 San.guinetti Ln. Stockfon, Ca. 95205 <br />TANK ID #39 - <br />SECTION - <br />39 -SECTION- 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: STOCKTON SERVICE STATION EQUIP. <br />Address: <br />820 No. Union St. Zip: 95205 <br />Stnr_krnu- CA Phone#: 464-8331— <br />Telephone: <br />64 R331 <br />Telephone: (2 0 9 46/t-8333 pate Tank Removed: <br />SEiCTION 3 -To be filled out by conte "decontaminating tank": <br />Tank Decontamination,f Contractor . CKTON SERVICE STATION EQUIP. <br />820 No. Union St. <br />Address: zip: 95205 <br />Ca- Phone#: 464-8333 <br />1 <br />Authorized represen tive of contractor certifies by signing below that the tank has been <br />decontami ted 'n an ppr -manner as many be regulated by Department of Health Services. <br />FIELD ASSIST. <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 accepting tank. <br />Facility Name <br />Address: 740 No. Wilson Way Zip: 95205 <br />Phone#: 466-6875 <br />Date Tank Received: <br />-- AUTHORIZED SIGNATURE AND TITLE <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. 90X 2009 <br />STOCXTON, CA 95202 <br />