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1.7 O <br /> QNDERCRC" D TANK DISPOSITION Qc I HG L-4-Ro <br />/t,,,ro,H, <br /> The San Joaquin Local Healtri Dletrict 's acking Sheet Will acCotapeny Moh tank <br /> its site ldenttllcatlon nWrstmc . The Tracking Sheer is to be >returan�:to ;$#`n <br /> Joaquin Local Health District vithin 34 days of acceptance of the tank by 416p084.16as I <br /> xwcyaling facility. <br /> a[lsUjgg Qat this,- &ggM ig,.'ZaMQleted,aW returned, -• <br /> FACILITY NATE; CLARK WELL, INC <br />]FACILITY ADDRUS. 2024 EAST GARTER WAY, STOCKI'ON, CA 95205 MAR 2 7 <br /> EM 1r R <br /> f iv :,�.,+ � L � EhL I <br /> TAW ID 139- f ERM'VrlSERVICE5 <br /> w,trww�r�r�ewx�rwwrew*fir*wwrr�*,r*x*x*xxxxA* Rx4xax AtIAAAARxxxxxxRx*xiF <br /> 82MION - 2 - To be lilled out by tanx removal contractor; <br /> Tank Removal Contractor ; FALCULA ENERGY <br /> A�ddres : PFO, Box 1257 Z W 95201 <br /> Phone#i <br /> To Is phone t (2M,,,,_? Date Tank Removed: <br /> �. <br /> SWrION 3 -To be 1111ed out 'by contractor "decontaml ting tank"; <br /> TV* Decontamination" Contractor ; FALCON ENERGY <br /> Addrew Zip <br /> hone JI i <br /> Authorized representative of contractor certllles by signing below that the tank has beeryp <br /> decontaminated in an avotoved manner as many be regulated 'by Department of Health �i'iY4w* <br /> JAMES J. HOBLITZELL, V, & ENVIRONMENTAL MANAGER <br /> 9 T GNATVRE AND TITLE, E <br />�rrrw**�tXw*r�Kwww*,R rr*�r�xxxxsRxRR,r�xwRRx�*xwx�****xK.xw*xwxww*wwkkwwwrrw�*�r�*�**�1r*�1�wx�tw <br /> SUMION 4 -'To bo tilled out and aiQned by an authorized zapreanetativs of the t Mg 4. <br /> storage, or dlaposal facility accepting tank . <br /> Facility name i� <br /> 424 TEGNER ROAD �f <br /> Jlddreasrs: <br /> TURI QCX,- CkL-I F0.R_N_1_A_ L <br /> Ph �d9r <br /> onaj, �F <br /> Date Tank Received; z <br /> r4R.Cf�{ l <br /> ANTIIOR I Z ED SIGNATURE AN TITLE �N <br />*#sarars�rwww*xrrirwwwwwww**R11�iXR.R*1iRRXxRXkI1XRR*kRIxRRw*** *�r***wwrr,r*,rw,�e*,�*�;**�;*rrww�rsews**�,w�,*� <br /> ICU 23049 17/80 <br /> KAIL100 IN87RUCT'ION9 t nLD IN HALF AND STAPLC, ix PROCTER POSTA(Z, <br /> SAN JOAQUIN LOCAL, tEkLTH DISTRICT <br /> AWN; UNDERGROUND TANK PROGRAM <br /> P . 0. AOX 2009 Ip <br /> ST003 'MN, CA 95202 i <br /> yl/9 cep �( F-fr— r,", �o '—s—erefi� ✓r te, i apt <br />