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SAN JQAQU2l�I LQC.2�.t� F-iE_x+.r TH D= ST'R2CT <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 permit with number noted below is responsible for <br /> ensuring that this form is com leted and returned, <br /> FACILITY NAME• Graphic Contractor <br /> FACILITY ADDRESS: 1325 West Weber Ave. , Stockton, CA <br /> TANK ID #39- - ±70�' <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Dobbas, Inc. <br /> Address: P.O. Box 177 , Newcastle, CA Zip: 95658 <br /> Phone#: 1916 ? 663-336 <br /> Telephone: ( 916 ) 663-3363 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Not Applicable <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 accepting tank. <br /> Facility Name Erickson InC-. <br /> Address: 255 Parr Boulevard Richmond, CA Zip: 94801 <br /> Phone#: ( 415) 235-1393 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TI'T'LE <br /> Ell 23 049 12188 . <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDMC ROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> ST=TON, CA 95202 <br />