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S.i'�N J'O?�►rq,U I N i.00.�L I-TE.la1w.TH DISTRICT <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 hg1der of tW permit with t o <br />gnsuring that this form is cola2leted and returned <br />FACILITY NAME: Knox s Texaco Food Mart <br />FACILITY ADDMS: 633 E. Victor Road, Lodi, CA .95240 <br />TANK ID 839- <br />SE:.TaO: - 2 - -To be fi;'sed o"t by tank removal contractor: <br />Tank Removal Contractor: 0 i 1 Equipment Service <br />Address: PO Box 950, San Andreas, CA Zip: 95249 <br />Phone#: _2Q2-7�4-18_ 08+, <br />Telephone: ( 209 ) 754-1808 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: nil F ❑ i o m . n t S gr v i_ ce _ <br />Address: Pn Rnx 9501 San Andreas • CA Zip: 95249 <br />Phone#: 209-754-1808 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manne.s wjz recyulated by jOgrarti4ent of Health Services. <br />Keith A. Tallia. President <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 Triangle Inc.'of Sacramento <br />Address: 3525 - 52nd Ave Zip: 95823 <br />Sacramento CA Phone#: 916-421-1990 <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TIME <br />E11 23 049 12188 <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 />