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• SAN .70AQJI N I,OC-kr • HIE AITH�L I S`rE I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> **x*w******wxww*wx*wwww*w*w***xxxxxxWxxxxwx*WWxWxxx**WwW*x****xWw***xx*****w**wwx*wwwww**x <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 <br /> returned. <br /> FACILITY NAME: V I { L^ Z, Cl ( L> <br /> FACILITY ADDRESS: 56113E FREhUNT STREET, STOCKTON, CALIFORNIA <br /> TANK ID #39- r;�"1 j 0 - 0 / Poo r>cY-C EN� PREMfA <br /> SECTION - 2 - To be filled out by tank removal contractor : PERMIT/SERVICE <br /> S <br /> Tank Removal Contractor: FALCON ENERGY ASSOCIATES <br /> Address: P.O. Box 30356, STOCKTON, CA zip: 95213 <br /> Phone#:()nal LiR'� ;1 wR <br /> Telephone: ( ) Rate Tank Removed:Mb1eG�. �q/� <br /> x*w***********ww******x****x*****Wxx*******x*************w****w***xw***WWw**w*********xwx** <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor : FALCON ENERGY ,ASSOCIATES <br /> Address: P,0. Box 30356, STOCKTON, CA _zip: 95213 <br /> Phone#: <br /> Author iz representative o cont actor 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 /> \1 .- k I QDn <br /> SIGNATURE AND TITLE <br /> ***www******w*www* **wwwwww **w*w*****www*w*wwwwww*****wwww*x****xwww********ww**xWx <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the XC14V004M <br /> 9(�XXLii(Xffi1�}ll( facility accepting tank . <br /> Facility Name THE LERNER CO, <br /> Address: 2711 'VVY DR. , STOCKTON, CALIFORNIA Zip; 95201 . <br /> , A( Phone#: (2 J <br /> Date Tank Received: 2� Ivl ArV_r� <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ****ww*xw***w**w**w**w**x**xxxx*xxxxxxx**Wxxxx*xxxWx*wxxx***W*******w*****ww*************xx <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />