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0 j 53 <br />SAN JOAQTJIN LOCAL HMAI •TH DIS'T`RICT <br />UNDERGROUND TANK DISPOSITION TRACKING RECORD <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: Mrs. Ann Tugel Residence (Previously a -farming operation.) <br />FACILITY ADDRESS: 8590 W. Valpico Road, Tracy, CA.:95376 A4.-�%/ 2' yg-Ile) - <br />TANK ID N39- <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />1201610673 <br />ERICKSON, INC. <br />Ave., Ste. 103, Fresno, CA. <br />Telephone: ( ) Date Tank Removed: <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: <br />Address: <br />Zip: 93711 <br />: _(209) 432-9005 <br />Zip: <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 $RICKSON, INC. <br />Address: <br />1 <br />Date Tank Received <br />AUTHORIZED SIGNATURE AND TITLE <br />Ell 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 />STOCKTON, CA 95202 <br />ZTp i7=7= <br />