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_JUN 13 '91 13:26 . P.313 <br />UNDERC, OUND 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 clays 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 comnleted arra re=ned,. <br />FACILITY NAM: Pac c Bgjjj <br />FACILITY ADDRESS: 1.24 West Elm Street, Lodi., California <br />TANK ID $39-n......�,.,b� OS`�a�,�\ <br />SECTION - 2 - To be filled out by tank removal contractor: �� Q <br />Tank Removal Contractor: American Environmental Management Corporation <br />Address: 9719 Linc <br />ve, Suite 501 <br />Zip: 95827 <br />#: (91 364-8872 <br />Telephone: { s16, ) 364-8872 Date Tank Removed: 2.3 &)2/L <br />�xxxxxxx��**xxaexx�xxxarxarxxxxx��:tat*�*�**��******at:ka>:a>;xxxx**�*****>Y��rx***�rxxxxx <br />SECTION 3 -To be filled out by contractor "decon6aminating tank.": <br />Wank Decontamination" Contractor:kel�- <br />Address: r -5r , . . VL'- Zip: <br />--► "2 ' Qo- Phone # : j � % s�3 �►� <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 />iiia,•isi�yr******yc*ie****tic**�**at;t********die*fir*iex*ic*��**ie*xxiexxx7e�*******,�**x*�c�rxxx*�r�r*******��e <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Faciiity.Name Erickson, luc. <br />Address: 255 Parr Boulevard Zi 94801 <br />Richmond, California Phone#: e lf23�� 1, <br />r� — — <br />Date IQ, ReceYvecti. <br />AUTHORIZED SIGNATURE AND TITLE � <br />xx:a*aYx,k*aY***�k'*tk*********7�*'****fie*******fie****�t**alt****dr**�Y*,Yee*it�rpltx*fkx�FieiCYr***Yr�k9ryr*Yc�C7kX�C*7kYtkak�kY�'* <br />Sfr 23 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL, HSALTii DISTRICT <br />ATTR-. UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />JUN 13 191 12:24 PAGE.003 <br />