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SAW aC]AQUI I4 LCJCAL.A HFp�TH 01S`T'FtI C�rr <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SEC'T'ION 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: sahargiin P1 umhi ng <br /> FACILITY ADDRESS: 2216 stewa rt. St. _ <br /> TANK ID #39- <br /> SECTION <br /> 39 SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address:2076 Acoma St . Sacramento Ca . _ _ Zip: 95815 <br /> Phone#: 927-8155 <br /> Telephone: ( 916 ) 9 2 7-Q 15 5 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: PCI Environmental Engineering - -_ <br /> Address: 2076 Acoma St Zip: 95815 <br /> Sacramento , .Cal Phone#: 927-8155 <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 /> 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 Cal Coast Disposal <br /> Address: 424 SO. Tegner Rd . _ Zi •95380 <br /> Turlock, Ca . _,_,_... ..,_.._._r._-.... phone#: (20 634-9_ <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Elf 23 049 12/88 <br /> 14AILING 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 />