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sz+," oc)Ac CJI:iV LCOCAL ?<-rm2u,TH 01SSIFZ1C'3' <br />UNDERGROUND TANK DISPOSITION TRACKING RDCORD <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 notgd,below-is responsible for <br />ensuring that this form is completed and returned._ <br />FACILITY NAME <br />Renal/Wickland Oil #604 <br />FACILITY ADDRESS: 1448 N. E1 Dorado �7 <br />TANK ID 039- 5j Z)OO <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: T wn And Cniintry rantrncrara Inc <br />- <br />Address <br />117 Otto Circle Sac. Ca.95822 <br />Zip: <br />Telephone: ( 916 ) 399-1960 Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: HERBST ENGINEERING. INC. <br />Address: 5980 -24TH ST. SACRAMENTO, CA.95822 Zip: 95822 <br />Phone#:916-422-2628 <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 CROSS EQUIPMENT COMPANY <br />Address: 11315 SOUTH BRIDGE STREET, Zip: 95670 <br />RANCHO DORDOVA, CALIF. Phonel:916-635-6680 <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 019 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ARFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />