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S .AN -7 02- DOSITEON TRACKING RECORD LAqDERGP%OUND TMqK DISC * i7 :k 'k, :k- .k- A, k -A, +: :k, A, "k, A, "k, :1'k, I., SECTION 1 The San Joaqui,-i Local Health Dicl-trict's Tracking Sheet will accompany each tank 'affixed with its site identification MI I TLLX_'r 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 o*f the prmit-_ with number noted below is resoonsible for that this form is completed and returned. FACILITY NAME: Precissi Flying Service :FACILITY ADDRESS: 11919 W. Lower_SacramentoRoad, Lodi, Ca 95242 .''**************k***„TANK ID #39- 2509-- (of k ik )k t kk' ,A; A* .k, A: 'k A k, k,k*)k ,k 'k -,t :k, .A: ;k, -,k- k A”�k: t :k t t 'SECTIO! - 2 To be filled out by Lank removal contractor: Tank Removal Contractor: Western Meter Service, Inc. :Address: 2735 TeePee Drive, Suite E., Stockton, Ca 95205 Zip: Phoned : (209) 948-6124.,: Telephone: 2[)9 9486194 Date Tank Removed: ,.1,SErrI0N 3 -To be filled out by contractor "decontaminating tank": Tank Decontamination" Contractor: Western Ddei-pr Service, TnC- 'Address: 2735 TRPPee Drive, Suite E, Stockton, Ca 95205 Zip: PhoneN: (209) 948-612A 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.' S I CNATURC AND TITLE SECTION 4 .7 To be filled out and signed by an authorized represnetative of the treatment,. `storage, or disposal facility accepting Lank. Facility Name Triangle Inc. of Sacramento Address: 3525 52nd Avenue, Sacramento, Ca 95824 Zip: Phone': 'Date Tank Received: AUTHORIZED SIGNATURE AND TITLE EH 23 049 12188 MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. Al, FIX PROPER POSTAGE. SAN JOh.QUIN LOCAL HE,'ALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P. 0. BOX 2009 STOCKTON, CA 95202