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0 <br />*lrititlrrrtc*�r>Y*>k*ir��t****st**rr*it>kititit�**********itiritltit***1r*�***�***sir*pit**itit�t*****irit**sit*�**��*it�tirt <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 gf tbg w1mit witb nuabgr notedo <br />FACILITY : Knro-xFs Texaco Food Mart <br />FACILITY S: 633 E. Victor Road, Lodi, CA -95240 <br />TANK ID 839- -Ot <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Oil Equipment Service <br />Address; PO Box 950, San Andreas, CA <br />zip: 95249 <br />Phone#: •Q 4 -1.._ <br />Telephone: ( 209 j 754-1808 Date Tank Removed: <br />iritic*lritititititititirir*Ir����*�ititlritititit*�*>t>rit�rit�irir�itir*lririr*iririt�ititir*it*iritic***iter***��*ir>rit**lrirsitir*****ititits <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Address: E0 204 950. „5an al==as, 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 manner as may be regulated by Department of Health Services. <br />Keith A. Tallia, President <br />SIGNATURE AND TITLE <br />�**�*itis******�tsir�ritirititiritiritiritirir*it�it�t*iririr**ic*itir*�**�*it��t*ic**�irir*rt******irir*it******rcpt*ir*rc*****�* <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 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 TITLE <br />*irit**�*�**�iritirirititltitirirlt���*itiririritit��*itsirititirititir>tit�lr�ititiririt*itxr�r*��**ir*itir>r�rir�rrir***it**rc****�*��*irir <br />Elf 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATI -A: UNDERGROUND TANK PROGRAM <br />P. • BOX 2009 <br />STOCKTON,95202 <br />