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T UE 1 :� F[ AP1 C ON . F' - 1-13 <br /> AO <br /> SAN JOAQU.TN LOCAL HM T. M 01 STRICT <br /> UNDERGRODND TANK DISPOSITION TRACKING REOORD <br /> x#*#x**#xxx**xx*x*#x#*x**#*xx***x#x#xx***x****##**##x**##***xx**x**xx**#**x***xx*##x**#**x# <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 Loral 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: RAINBO BAKERY <br /> FACILITY ADDP.F-SS.__jO8 EASTWALNUT STREET, L DI <br /> TAMC ID 139- / �� - 01 coo <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: RAMCQN <br /> Address: 1401 HALYARD DRIV .! SLATE 130 zip. 95691 _ <br /> WEST SACRAMENTO, CA 95961 Phone#: 916 372-7535 <br /> Telephone: ( 916 ) 372-7535 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" C.ontractort RAMCON <br /> Address: 1401 HALYARD DRIVE, SUITE 130 zlpt 95691 <br /> WEST SACRAMENTO. CA 95691 Phone#: 167777777— <br /> Authorized representative representative of contractor certifies by signing below that the tank has been <br /> decontaminates approv dttan/� may be regulated by Department of Health Services.- <br /> 97rVATURE AND TITLE <br /> SEXTION 4 - To be filled out and signed by an authorize represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name„ TRIANGLE CONSTRUCTION <br /> jdre: 3525 52nd AVENUE z1o: 95823 <br /> SACRAMENTO, CA Phone# : 916/421-1990 <br /> Date Tank P.ece d: b - - R <br /> _ dY1t,� 1 e� <br /> AWHORIZED SIGNATURE AND TITLE <br /> EN 23 049 12/88 <br /> MAILING INSTR1R:rioNS: FOLD IN HALF AND STAPLE. MVIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROI'ND TANK PROM M <br /> P. 0. DOX 2009 <br /> STOCKTON, CA 95202 <br />