Laserfiche WebLink
SAN 702--QLIIN LOCAL. 14MAr.TH DISTRICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />.*x*xxx****x**x********x*x**R****tk*****x****xxlhx*ilxxxxR***RxihlFfifi*xltlFx*R**RRR*fiRRRR**RxRRRxR <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 cermit with number noted below is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME <br />Reeal/Wickland oil 1!604 <br />FACILITY ADDRESS: 1448 N. E1 Dorado <br />- D 3 r��J�LrLCI� <br />fix <br />TANK ID M39-***x***xfi * fifiR*RBBB fiRRR <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Town And f nim [,�y rnntrnr nrn To, - <br />Address: 117 Otto Circle Sac. Ca. Zip: 95822 <br />Phone►: 392-1860 <br />Telephone: ( 9I6 ) i92-ta6o Date Tank Removed: <br />**xx***x*xxxx*****x**x*x*x******x**x**x*x*****x*x*Rx*RR*R**xx*x***x*******xxx*xRRRxRR*RxxRR <br />SECTION 3 -To be filled out by contractor "decontaminating tank":, <br />Tank Decontamination" Contractor: HERBST ENGINEERING. INC. <br />Address: <br />5980 -24TH ST. SACRAMENTO. CA.95822 <br />Zip: 95822 <br />: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 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALT AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />