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is d <br /> MAP 17 '99 09:55 PETROLE ENGINEERING 7075457068 P.6 <br /> • SAN �?C�AQ,t,.J�1V Z.c�r�.r. �#�rp,,�.'�'1-i L7 I S TR I CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION I -- The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> aftixed 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 at <br /> recycling facility. he OtMiL withfol <br /> ensuring that this orm is co WAted and returned <br /> FACILITY NAME: "FAST GAS" <br /> FACILITY ADDRESS: 800 EAST HWY, 12, LODI <br /> TANK ID 439- - <br /> w�rx*�**�*�*******�k�r�rr�w�k***���*****�*******�*�***�t�rr�*sr**w�rw���***�**:4*******,k*****sr*:. . <br /> SECTION -• 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: PETROLEUM ENGINEERING, INC. <br /> Address: 11 WEST NINTH STREET, SANTA ROSA, CALIFORNIA Zip: 95401 <br /> Phone#: 707-545-0360 <br /> Telephone: ( 707) 545-0360 Date Tank Removed: <br /> SEGTZON 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: H & H SHIP SERVICE <br /> Address: 220 CHINA BASIN ROAD, SAIF FRANCISCO, CALIFORNIA Zip: 94107 <br /> Phone#: 415-343-483F— <br /> Authorized <br /> 1 3+3-435Authorized 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 TRIANGLE, INC. <br /> Address. 3525 52ND AVENUE, SACRAMENTO, CALIFORNIA Zip; 95823 <br /> Phone#: gy6.1,91_j aan <br /> Date Tani. Received: <br /> a AUT140R I ZED SIGNATURE AND TITLE <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOX AL HEALTH DISTRICT <br /> ATT'N: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />