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SAN .70Ao TN LOCLAL. HEAL, I'li �Y SZ'F22 L"'1' <br /> � J <br /> UNDERGROUND TAMC DISPOSITION TRACKING RECORD <br /> !*!tt!!ltRf«RtR****#i!!*R*XX!!**RR«RRx#x#tR2Xx!*2!fi*tl2;R*R2R2*RRRlR*RRR*;t**#R*!*#X*R*l2Rt <br /> SHOTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed vith its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Loral Health District vithin 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder ofthe cermit v1Gb nlm'�!�er noted below is responsible for <br /> �na�{na that this form is omnlettd and returnees <br /> FACILITY NAME: Buffalo Tank Corporation <br /> FACILITY ADDRESS: 5709 E. Fremont Str;,et, Stockton , CA <br /> TAMC ID 839-_ �5�75 - Off- 1 -2,:)00 gal . Reg. k;as tank FPA Site :-CAC 000215665 <br /> SECTION •- 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorre Oil , Inc. <br /> Address: 351 N. Beckmar Road, Lndi , CA Zi 05)40 <br /> Phone#: 2J97_777)7-5 -) <br /> Telephone: ( ? Date Tank Removed: /13019 <br /> — <br /> SWTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM 1F'.02PE OIL, INC. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckwan Road , Lodi , CA yip. 95240 <br /> Phone#: (209) 36d-5175_ <br /> Authorized representative of co tracto certl:les y signing belov that the tank has been <br /> decontaminated in an approved Hoer s lated by Department of Health Services. <br /> C- _ Vice-President <br /> I E <br /> AND/ITLE -- -- --�-- <br /> *!*#!***!2«RR*RRxRRqille=ut <br /> SHCTION 4 - To be fand signed by ar. uthorized represnetative of the treatment, <br /> storage, or disposay accepting t nk <br /> Facility Name— <br /> Address: 12000 FOLSOM BLVD. <br /> ----nANCFIf1.COanrniA r.A °574' <br /> 916-985-4810 - Phone#: <br /> Date Tank Received:---�/ �— <br /> AUTHORIZED SIGNATURFAAND TITLE <br /> EH 23 019 12188 <br /> HAILING 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 /> STOCXTON, CA 95202 <br />