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SAN JOAQILJIN LOCAL H AL rrH DISTRICT <br />**************k***k***kk***RR****RR****k***kk*kkk*k*kk*kkk*kk****k*Rkk**R*******k****k****R <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: 6OTELLI LIFT TRUCK SERVICE <br />FACILITY ADDRESS: 1856 N. BROADWAY, STOCKTON, CALIFORNIA 95205 <br />TANK ID 139- I `/Z% - OZ <br />*k***kR****k******R**k*****R*********k****Rk*******k********kR*R*R***k*****k*********k****R <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: FALCON ENERGY <br />Address: P.O. Box 1257 <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: FALCON ENERGY <br />Address: P.O. Box 1257 Zip: 95201 <br />CALIFORNIAPhonel: r�na� nr� �inQ <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 />.P. & ENVIRONMENTAL '`TANAGER <br />SIGNATURE AND TITLE <br />SECTION 1 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal faculty accepting tank. <br />Facility Name LAL LOAST TANK <br />Address: 424 [EGNER ROAD Z <br />1. Olt <br />19 <br />'1 <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />************************RR****R*R*****RR****RR**********Rk*R************k******RR********** <br />Ell 13 019 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERMOUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />