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r �• r- • r r • r r - • � - ��s - r <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 ggrmit with number noted below is responsible for <br />ensuring, that this form is completed and returned. <br />FACILITY NAME: Pacific Bell <br />FACILITY ADDRESS: 124 West Elm Street, Lodi, California <br />TANK ID #39-�®Z <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#: (91b) Jb4-667T <br />Telephone: ( 916, 364-8872 Date Tank Removed: <br />SEC'T'ION 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 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 Zip: 94801 <br />Richmond, a morn a Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />*ik*itik'it�eic9caY***�k9t9c*�k***�k�YititiC�Y�Ir9e9:ie�k�Yieicie�k�9rik�tiesr�Yie�:ksYt�Y9e�k�Csti**�t'�tie�'***xt:�:@*ir:FYt�k*9c�k**s@**�ti�9t*�l�ck�k�h�k� <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 : UNDi t2GROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />