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iF <br />SAN J C?AQU I N 1_,C7CAJ[, HI Zak�U'H D 15'I"j;Z ICT <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 arc:eptance of the tank by disposal or <br />recycling facility. The holder of the Permit with numbed noted bglow is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: CAL -PACIFIC FOOD SALES, INC. <br />FACILITY ADDRESS: 125 EAST MAIN STREET RIPON, CA. 95366 <br />TANK ID 939 - <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: SHAW MAINTENANCE, INC. <br />Address: 928 W. GLENWOOD AVE, TURLOCK, CA. Zip. 95380 <br />209768-8441 <br />68 - <br />Telephone : ( 209-) 668-8441 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: SHAW MAINTENANCE, INC. <br />Address: 928 W. GLENWOOD AVE, TURLOCK, CA. Zip: 95380 <br />Phone#: 20668-8477 <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 <br />Address: <br />ip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />EH 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPFR POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATPN: UNDERGROUND TANK PROGRAM <br />P. 0. SOX 2009 <br />STOCKTON, CA 95202 <br />