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11 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*rtw*wk+wwirrtW Wrtkit4wt33333+w►rriiYYYt++tiYiiiiiiiiiYYYtiYirrii+Yitr*rwrWiriirrir+tYY4YiiiYrrrwti++iWrrirtwYi <br />SECTION 1 - Public Health Services Eaviromnental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />FACILITY AD <br />CAPITOL AUTO SALES <br />650 E. MINER AVENUE, STOCKTON, CA 95202 <br />TANK ID #39 - TANK SIZE: EST . 1, 0 0 0 A&IOUS TANK CONTENTS: GASOLINE <br />WW Wi#+wwrrt#ww#44r4irtWiriiiiW4Wrti#rwWr#++iiw��iwir+irwrrirrrtiW4tiirrrtiW#wrwirwiiiwrrwk4ktiiiYwkWiwwrtww#kwwwW <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM HO B L I T Z E L L <br />Address: BOX 30331 <br />Phone N: ( 209 943 7793 Date Tank Removed: <br />city: STOCKTON, CA Zip:95213 <br />trt###4WWirtwww##kiriWWi+liii#irWwWiii+i+riii+iWii+i+t++#tikkYr#wwkw##wrtrtiwrtiii+wi+rrrriYiriri#wiwkkY4Wkiiwwt <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: JIM HOBLITZELL <br />Address: <br />BOX 30331 <br />Phone N: ( 209 ) 943 7793 <br />City: STOCKTON.CAZip: 95213 <br />Authorized representative of contractor certifying tbraugh signature below that the [atilt has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: Signature: Date <br />krtwrtrt+++www+www+w++Wt+ii44WwWi4t+r►r++rrrrtrrrrtirit+i+itNir++ttiiirtrtw4#+ii++4rrrrt+irrrriww+++wwww+++rtrt*+ <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: WEST COAST EQUIPMENT <br />BOX 2368 <br />Phone q;( 209 ) 668 9378 <br />Date Tank Received: <br />Name: <br />City: TURLOCK,CA <br />Title: _ Signature: <br />Zip: <br />95381 <br />Date <br />rt4w##rtk+rrtw#irtrt4iiri+WiiW+W4rw+i4Y++ii►+trY*rtitt+iriYWti#iii+ii4iirtrti+iwit3334+wiii4wrirrtw++wrW+iWrrwwrt+W <br />EH 23 046 (Revised 10/19/98) Page 10 <br />