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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> t x z x x x t x t t x t x z x x t x z t x t t x t t t t t x x t z x x <br /> SECTION 1 - The San Joaquin Local Health District's Tracking Sheet <br /> will accompany each tank affixed with its site identification number. <br /> The Tracking Sheet is to be returned to San Joaquin Local Health <br /> District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with number noted above <br /> is responsible for ensuring that this form is completed and returned. <br /> FACILITY NAME: 7-11 <br /> FACILITY ADDRESS: 455 W. Grant Line Rd. , Tracy CA TANK ID 939-/2!i�t -0/ <br /> t x x x z z t t z z t t x z z z z z z x z z z z x x x x t z x t x x t <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Petro-Check, Inc. <br /> Address: 271 Opportunity St. , Suite C phone 9 (916) 927-8155 <br /> Sacramento, CA Zip 95838 <br /> Date Tank Removed <br /> z z z x t x x x z x z x x z z x x x z z z z z z z x x t t t t z t x x <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank "Decontamination" Contractor <br /> Address Phone# <br /> Zip <br /> Authorized representative of contractor certifies by signing <br /> below that the tank has been decontaminated in an approved manner <br /> as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> x z x t x x x x x x t x t x x t z t x t x x t x t z x x t z z x t z x <br /> SECTION 4 - To be filled out and signed by an authorized <br /> representative of the treatment, storage, or disposal facility <br /> accepting tank. <br /> Facility Name Refinery Services, Inc. <br /> Address 13331 North Highway 33 Phone# (800) 874-4444 or (209)892-6742 <br /> Patterson, CA Zip 95363 <br /> Date Tank Received <br /> AUTHORIZED SIGNATURE AND TITLE <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P.O. BOX 2009 <br /> STOCKTON, CA 95201 <br />