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JUN 13 '91 13:25 P•2/3 <br />SAIF 7C7.A.QU3:X4 L.GCA.L 14MAX.T`H DS ST1:;.1x CZ' <br />UNDERGROUND TANK DISPOSITION TRACUNG REMRD <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 Distric6 within 30 day's of acceptance of the tank by disposal or <br />recycling facility. Th holder of the Hermit with number noted below is resRgnsi_ble for <br />ensuriM &hat this form is completed aV3 returned. <br />FACILITY NAME: . Pacific Bela. <br />FACILITY ADDRESS: 124 West Elm Street, Lodi, California <br />TANK ID #39-. t9t& <br />SECi ION -- 2 -• To be f i l led out by tank removal contractor: <br />Tank Removal Contractor.- American Environmental Management Corporation <br />Address: 9719 Lincoln Village Drive, Suite 501 Zip: 95827 <br />Sacramento, California p pn�#. (916) 364-8872 <br />Telephone: (. 916 ) 364--8872 _- - ..Date Tank -Removed: A' !L RCI <br />SECTION 3 To be filled_ out by contractor "decontaminating tank".- <br />Tank <br />ank": <br />Tank Decontamination's Contractbr: <br />Address: <br />W� <br /># : L 2K__1 <br />Authorized representative of contractor certifies by signing belov that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURZ 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, Znc. <br />Address: 255 <br />Ric <br />Date Tank Tcivad:, •_ <br />91f 23 049 32/68 <br />MAILING INSTRUCTIONS: <br />AUTHORIZED SIGNATURE AND TITa <br />FOLD IN HALF AND STAPLE. Ar -FIX PROPER POSTAGE, <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN-. UNDMCROUND TANK PROC AM <br />P. 0.. SOX 2009 <br />STOCRTON, CA 95202 <br />Zip: 94801 <br />JUN 13 191 12:23 PAGE.002 <br />