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SAN JOAQLJ I N LOCAL HEALTH 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 /> FACILITY ADDRESS: <br /> 5643 E. FREMONT STREET, STOCKTON, CALIFORNIA <br /> TANK ID #39- <br /> W****W***W********W***W*W******W**W***W******W*W*WWW****WW***WWW**W*W************W*W***W**W <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: FALCON ENERGY ASSOCIATES <br /> Address: P.O. Box 30356, STOCKTON, CA Zip: 95213 <br /> Phone#:(2(19) 463_1f1�R _ <br /> Telephone: ( ) Date Tank Removed: <br /> ***************W********W*WW**W**********W****W**W***W********k******W*WW*****W*****W***kW* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: FALCON ENERGY ASSOCIATES <br /> Address: P.O. Box 30356, STOCKTON, CA Zip: 95213 <br /> Phone#: (209) Ltd_ <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 /> k***W*******W*******W***W*k******W******WW***W****W***W****k**W****W*W******k***kWkW*k***kk <br /> SECTION 9 - To be filled out and signed by an authorized represnetative of the WX0M <br /> ECdfiLdJ&ixX163( IC �af1C facility accepting tank. <br /> Facility Name THE LERNER CO. <br /> Address: 2711 %AVY OR. , STOCKTON, CALIFORNIA Zip: 0 <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ************WWW**********W****W*W***W***W*****W***W*W**W***WWWW*****kWWWWW*W*W***WWW*W**WWW <br /> EH 23 049 12/88 <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 />