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SAN JOA�.JIN LOCAL HEALTH DISTRICT <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 hermit with number noted below is responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: Frpn'.s Exxon #2 <br /> FACILITY ADDRESS: 1799 Ee s t Yosemite Avenue , 'ante ca , CA 91-336 <br /> TANK ID #39- 1�+ 1 - <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: 3 , C C o n s t ru c t i c n Company <br /> Address: =�-�7 N lershina , A-3, Stockton, CA Zip: 9F2(7 <br /> Phone#: (2C9 ) °�1-c 3C4 <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor• Shaw ,,'P i n t e n�n c e C c rr.T p n y <br /> Address: 92E '4. Glenwood Avenue Zip: 0 380 <br /> Turlock, Ca. Phone#: (269 ) 65)F-8441 <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 9 - 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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 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 />