REMOVAL_1989 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN LOCAL HEALTH DISTRICT FEB 11989 NE?,1TAL HEALTH UNDERGROUND TANK DISPOSITION TRACKING RECORD 1NIIf15ERVICES SECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the permit with number noted above is responsible for ensuring that this form is completed and returned. FACILITY NAME: Manteca Trailer FACILITY ADDRESS: 1990E Yosemite Ave. , Manteca TANK ID 039- - x x x x x x x x x x x xxx x x x x x x x x x x x x x x x x x x x x x SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Petro-Check Inc. Address: 71 npmrtuniL,4 St_ , S11i1PC Phone 0 (916) 927-8155 Sacramento, A _zip oGa-�R Date Tank Removed x x x x x x x x x x x x x x x x x x x z x x x x x x x x x x x x x x x SECTION 3 - To be filled out by contractor "decontaminating tank": Tank "Decontamination" Contractor Refirery Services Inc. Address 13331 North Hiahway 33 Phone# 800-874-4444 or 209-892-6742 Patterson, Ca Zip 95367 Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x SECTION 4 - To be filled out and signed by an authorized representative of the treatment, storage, or disposal facility accepting tank. Facility Name Tony Machado Address 12700 East Louise PhoneO 202-823-6U5 Manteca, CA Zip 95336 Date Tank Received AUTHORIZED SIGNATURE AND TITLE x x x x x xxx xxx x x x x x x x x x x x xxx x x x x x x x x x x MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P.O. BOX 2009 STOCKTON, CA 95201