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�I <br />sp,w oc:%A0LIS1-j LOCAL. 14 nr.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 holder of the permit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME- <br />Regal/Wickland Oil #604 <br />FACILITY ADDRESS: 1448 N.El Dorado <br />// <br />TANK ID 139- I � - Z_ �1?1 -/ (��Cl�l�� <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: 117 Otto Circle Sac. Ca. Zip: 95822 <br />Phone#: 392-1860 <br />Telephone: ( 916 ) 392-ig6o 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. Phonet:916-635-6680 <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 23 019 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 />