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AML <br />SAN acqQUIN, C CAL, i-iI~. AL L7 2 S TR = CT <br />��-r-• � � •• � -•• •ars-� <br />******************************************************************************************* <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`is'tesponsible for <br />ensuring that this form is completed and returned. <br />9 <br />FACILITY NAME: Pacific Bell V, AY D <br />FACILITY ADDRESS: 124 West Elm Street, Lodi, California <br />TANK ID #39 - <br />SECTION <br />39 -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: <br />C1 , <br />Zip: 9 a <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 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, Inc. <br />Address: 255 Parr Boulevard <br />Richmond, Califo <br />Date Tank Received: <br />Zi 94801 <br />Phone#: 9�! <br />— 9. 4 <br />AbTHORfZED XGNATURE AND TITLE <br />Ell 23 049 12/88 <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 />