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UNDERGROUND TANK DISPOSITION TRACKING RECORD A P R 2 0 <br /> SECTION 1 The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each-tank <br /> affixed with its site identification number. The Tracking Sheet isto 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 pf!rmit with number <br /> ensuring that this form is comiRleted and returned. noted below 1 s responsible for <br /> FACILITY NAME: GRAHAM ROYALTIES, LTD. <br /> FACILITY ADDRESS:- 9571 S. ROBERTS ROAD, STOCKTON <br /> TAW ID 939- ) -714 - 1 <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: WARREN E. GOMES EXCAVATING, INC. <br /> Address: P.O. Box 369, RIO VisTA, CA -zip: <br /> 471 - <br /> Phone#: <br /> Telephone: 707 374-2881 Date Tank Removed: & <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 TIME <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: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AIMORIZED SIGNATURE AND TITLE <br /> Ell 23 049 12188 <br /> 14AILING INSTRUCTIONS: -MLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL, HEALTH DISTRICT WARREN E. GOMES <br /> ATTN: LYNDEVGROUND TANK PROGRAM Excavating, Inc. <br /> P. 0. BOX 2009 <br /> STCK3(T0N, CA 95202 P. O. fox 369 <br /> Rio Vista, Cald 94.571 <br /> (707) 374-2881. <br />