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SAN aoAQUI N LOCAL HEAT •TH DI SU -al CT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <br />*****x*xxx*x***x***x#***###*#*#xxx*****xx**xxx***xx*xx*xx****x**x*xxxxxxxxxxxx*xxxxxx*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 disposa1,or <br />recycling facility. The holder of the permit with number noted below 1s responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: UOTELLI LIFT TRUCK SERVICE <br />FACILITY ADDRESS: 1556 N. BROADWAY, STOCKTON, CALIFORNIA 95205 <br />TANK ID 139- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: FALCON ENERGY <br />Address: P.O. BOX '1257 <br />Lip: 95201 <br />: (202) 465 ZIOR <br />Telephone: ( ) Date Tank Removed: <br />***xxxxxxxx******xxx******x***x*x**x*xx*xx***x***xxxxx*x*x**********xxxx*x*xxxxxxxxxxxxxxxx <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: FALCON ENERGY <br />Address: P.O. iOX <br />zip. 95201 <br />1: (24) ❑fZ 7102 <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 />SIG►' <br />�J `J SIGNATURE AND TITLE <br />SECTION 9 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name CAL LoAsT TANK <br />Address; 424 IEGNER ROAD Zip: 9538n <br />R1 OCK, CAI•: 1 I:Y4L•I111. <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 13 049 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. O. BOX 2009 <br />STOCKTON, CA 95202 <br />