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SAN JOAQT 7=N :C 0CZ1L, I iEALTf? DS S.r CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />XXXX*****************X'*****:t*%'**X•7::P%'*A"k%':l'k%'i:*:t****:k*%'**%k******:t****k***k**.*****�****X*XX** <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 />,Joaquin <br />facility. The holder o[ the r)ermi-t-, wi.t'h nLy r. noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: Brooks Products -- <br />,CILITY ADDRESS: 2441 West Charter Way Stockton, Ca 95205 <br />ID #39- <br />'******************************X•X'****X'****A'X*:l'X'XX'***X'X'X•X'*X•*%'X'X'***k*%X'****************** <br />ON - 2 - To be filled out by tank removal contractor: <br />Removal Contractor: Western Meter Service Inc. <br />2735 Teepee Dr. Ste.E Z-? I <br />95205 <br />Stoc ton,Ca Phonek. 2041-'518-6=: <br />:lephone: ( ) Date Tank Removed: <br />,m <br />=ION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: Western Meter Servicp.Inc. <br />'Address: -2735 Teepee Dr. Ste.E Zip; 95205 <br />Stockton, a Phone#:(209 948 - <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 />-***X*******:F******************X•**k***X'*X'1:**'A'R'k•kX"kRA'A•********************k******k**k******** <br />SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />Address <br />4jr <br />Date Tank Receivea: <br />_Zip: <br />fl : <br />AUTHORIZED SIGNA'T'URE AND TITLE <br />EH 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AI'FIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. 60X. 2009 <br />STOCKTON, CA 95202 <br />