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SAN 70AQU1N LOCAL H3_Z'2r. rI-i DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECCRD <br /> xzxslx::xx::sszxss:xx:sxxxxxxrszxxxxxxx:rxx:sxrxxxxxxxx:xxxx::xxx:xxxxxxxzxsxs:sss::xxssxxx <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 "5RQQg14 <br /> ensuring that this form is co 1 4 IU j <br /> i <br /> I,+<, <br /> FACILITY NAME: COLLINS ELECTRIC CO'!P : Y <br /> FACILITY ADDRESS: 61. J. Fremont Street MGR 311989 <br /> TANK ID 039- <br /> CNVRCN <br /> [�y`'iRCNP.4RNTP,i.K'LTH <br /> x*xxxxrxxxxxsxrzx:xzxxxx:xxxxrxxx:xx*xxrxxxxxxzxxxxxx:x:xrxxxxxrxxxxx '�} �tifmd�eexxxxxx <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tnk Removal Contractor: STOCKTON CONTRACT14G GROUP, INC. <br /> Address: 1000 N. Union Street Stkn. Ca. Zip• 95 05 <br /> Phone#: <br /> Telephone: ( 209 462-5082 pate Tank Removed <br /> xxxzxxxxxx:rxxxsxxzrxxxzxx:rxxxsxxxxxxrx:xxrxxrxrx:xxxxxxrxx:xxxxrrxxr:::sxxxxsxxrsx::zrxxx <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: STOCKTON CONTRACTING GROUP. INC. <br /> Address: 1000 N. Union Streer Stockton Ca. Zip: 95205 <br /> Phone#: (209) 462-5082 <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 /> z:xrxxxx:xxxxxx:xx:xxrxxrxxxxxxxxxxxxxxxxxxxzxxxxxxrxxrxxxx:xxxxxxrxrrx:xzsxxxrxxxxx:rxxxxx <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 Stockton Contracting Group, Inc. <br /> Address. 1000 N. Union Street St::n. Ca. ^n_ <br /> Zip: ` <br /> Phone#: '09, _6.'-5082 <br /> Date Tank Received: —g / —LIC/4 <br /> ��- 7 c-_ <br /> AUTHORIZED SIGNATURE AND TITLE <br /> xxxxxxxxxxxxxzzxxxxxzx:xxxzxzxxxxxxzx:xxxxxxrxxxxxzxszrxxxxx:xxxxxxxxxxxzx*xzxxxxzxxxrzxxx: <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 /> �,, l STOCKTON, CA 95202 <br />