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SAN JOAQLJIN LOCAL FMAT.,rH DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *****t**trtx**Xxx**xxx**t*x*****xx**x*x*x*xx*Xxx**XX******x*xx*****xx**x*x*x*x*x*x*xx*xx*xx* <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: Bill Caminata <br /> FACILITY ADDRESS: 11181 E. Baker Road Stockton , CA 95205 <br /> TANK ID #39-�-/ 05 - hQ�O qa� �Q rL <br /> *XXX***XXX*xx*xX****xx***x*Xxxxxxxx*x�xxxxxxbtxx**x**xxxx*xx****xx**xxx*xx**xxxxx*xxx*x*xxx* . <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Western Meter Service Inc . , <br /> Address: 2735 Teepee Drive Ste. E. Stockton, CA Zip: 95205 <br /> Phone#: <br /> Telephone: ( 209 ) 948-6124 Date Tank Removed: <br /> *****XX*****X***********X**************X*********XXxx************x***x*X**x**x*********X*x* <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Western Meter Service Inc . <br /> Address: 2735 'Teepee Drive Ste . E. Stockton, CA Zip; 95205 <br /> Phone#: ( 2098-6124 <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 /> /e Wes DuBose <br /> 4 SIGNATURE AND TITLE <br /> ***X*X***** *X*XX***X*k**X****X****xx**xXXx*xxx*XXX***X**XxX***x**xx*xx**Xx***X****X******X <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 <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> XXXx*X*XXX*XXX***X*XXXXXXXX***XX*X**x***X***x***X*Xx****XXx*******XA***X*********x****xXX** <br /> EI( 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 /> p0511 STOCKTON,, C2095 <br /> A 202 <br />