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F' - 0 r <br /> 5AN JOA�LJI N Z�OCAT� HEALTH DI �1TF2I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <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. Tb.9,_hgl¢er of the permit with number noted below 1s responsible for <br /> �n��x_1�s_,>it>���hi o •m .L5_.Gc� IR eted_..�s1_s��n�. <br /> FACILITY NAME: RAINBO BAKERY <br /> FACILITY ADDRESS: 108 EAST WALNUT STREET, LODI <br /> TANK ID <br /> ***************k****k**4**k***x***#***R*****k****R****#**k****A**************************R* <br /> SECTION - 2 -- To be filled out by tank removal contractor: <br /> Tank Removal Contractor: RAMCON <br /> Address: 1401 HALYARD DRIVE., SUIIE 130 Zip: 95691 <br /> _WEST SACRAMENTO, CA9_5,961 Phone#: 91fi./372-7535 <br /> Telephone: ( 916 y 372-7535 DAte Tank Removed:______ _____ <br /> SET ION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: RAMCON <br /> Address: 1401 HALYARD DRIVE, SU1T_L1.0 21 95691 <br /> _WEST SACRAMENTO. CA 95691 µ�� Phone#: 916737 ..x! <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 /> 3ICNA7URE AND TITLE <br /> *****RKY****k******************#*********k*****************kR***********k******k*k*********R <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 TRI ANGLE . QNSTR'JCTION ____ <br /> Address: -- 3525 52nd AVENUE _—Zip: 95823 <br /> SACRAMENTO, CA phone#.- 2;_4 4JL:1990 <br /> Date Tank Received: <br /> AIJPHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FIOLD IN HALF AND STAPLE. ArFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A7114: UNDMGROUND TANK PROMAM <br /> P. 0. BOX 2009 <br /> sTOc3KToN, CA 95202 <br />