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11 <br /> MAR 1E '99 14:5E, F'ETF'1CLEL IM ENI IHEERINIS 707514570rI=. F',r <br /> S A31V ti 0_7),Q1j 1 N ZjO(7 x, H0 '7'H D I S'M l C'T' <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 ".ne 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 /> : oaquin Loral Health District within 30 days of acceptance of the tank by disposal or <br /> -ecycling facility. The holder_ pf the rerMit with numbe >t1,Qted bel is respQnsible .for <br /> tasutino that this tors completed and_;e urned, <br /> FACILITY NAME: "FAST GAS" <br /> FfiCILITY At DpESS: 800 EAST HWY. 12, LODI _-- <br /> TANK ID 439- - <br /> E..TM2 m Tu 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 /> Tp leLhone: f 707 ) 545--0360 Date Tank Removed: <br /> SECTION 3 -mo be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: H & H SHI? SERVICE <br /> Address: 220 CHINA BASIN ROAD, SAN ,FRANCISCO, CALIFORNIA Zip: 94107 <br /> _Phone#: 413-543-4835— <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 /> SECTION 4 -- To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Narne TRIANGLE, INC, <br /> Address: 3525 32ND AVENUE, SACRAMENTO, CALIFORNIA Zip; 95823 <br /> Phone#: 416"491-199n <br /> Gate Tank Received; <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 049 12/88 <br /> ;,A,x I,I NG I NSTRU-'rI ONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P, 0. BOX 2009 <br /> $7raTON, CA 95202 <br />