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5AN .�QAQU2N L,O�AT, K�'ALTH DISTR.2�T <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_n_oted_below_is _responsible for <br /> - <br /> ensuring that this form is completed and returned <br /> FACILITY NAME• General Potato & Onion <br /> FACILITY ADDRESS: 1541 West Weber Ave. , Stockton, CA <br /> TANK ID #39- ) Z S - OZ G,OCD �/4i_- ZG' e.4- �i'4_-, <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Dobbas, Inc. <br /> Address: P.O. Box 177 , Newcastle, CA Zip: 95658 <br /> Phone#: ( 916 ) 663-3363 <br /> Telephone: ( 916 )663-3363 Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Not Applicable <br /> Address: Zip: <br /> Phone#: <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 /> *********iC*************�t*YciC*icYr7c***Yr*7r*it***7kkYc�k*7c*1c*•irk***ic**:F******7tJa*jk**Yr�t*fit*itYc******ir****k <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility acepting tank. <br /> Facility Name Erickson, Inr=. <br /> Address: 255 Parr Boulevard, Richmond, CA Zip: 94801 <br /> Phone#: ( 415) 235-1 <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> Elf 23 049 12188 , <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. ArFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANG PROCIZAM <br /> P. 0. BOX 2009 <br /> STOCCTON, CA 95202 <br />