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I <br />�, �, SAN .7 - LJ = N L C CAL HEP T • i� I S TR 2 CT <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 permit with number noted below o 1ble'-for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: Pacific Bell <br />i J <br />FACILITY ADDRESS: 124 West Elm Street, Lodi, California _ i <br />P117-17" <br />7-3 <br />TANK ID # 39 -_0�0 <br />SECTION - 2 - To be filled 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 Phone#• (916) 364-8872 <br />Telephone: ( 916 ) 364-8872 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: _A0 Zip: <br />Phone#: <br />Authorized representative qf contractor certifies by signing below that the tank has been <br />deco mi ted in n app ed manner as may"recq�ulltedby Department of Health Services. <br />SIGNATURE ANge4rITLE <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, Inc. <br />Address: 255 Parr Boulevard <br />Richmond, California <br />Date Tank Received: <br />Zip: 94801 <br />Phone#: <br />G - - <br />AUTHOR D SIGNATURE AND TITLE <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UND- GROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />