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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVrRONNtENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> «♦//rarraraaaarrrrraar+rrr+ra+♦r#rs#♦##r#+#rarrrr#/a«aarrrwrrrwrr#tarsaaraa•«sraaraaata/#r«rawrr#roar#ar«ar <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany eack tink 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: CHEVRON STATION <br /> FACILITY ADDRESS: 139 S. CENTER STREET <br /> 0It? 39Dj <br /> TANK ID#39- -38889- TANK SIZE: 10K PREVIOUS TANK CONTENTS: REGULAR <br /> rrrra##raa#raa/#r#•asrrrwaarrrarrra/rrrrrrrarraar#rr/r#rarrawr«+aaaaa##rarrrarraaaraaa+rarrrrrrrrrasarrrrra <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: MUSCO EXCAVATORS, INC. <br /> Address: 2526 GREENVALE COURT City: SANTA ROSA Zip: 95401 <br /> Phone#: ( 707 ) 579-0250 Date Tank Removed: <br /> rrr«r+auracarr/+r/rrr+rrrrrarr#rr+r+ar+rr+++rr/#♦a•rrr+raarrrr/rr«+r/+r«r+rr+aarrr#rrrrrwrr+r++ar+rrrr/rrr <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: E.C.I. <br /> Address: 255 PARR BLVD. City: RICHMOND Zip: 94801 <br /> Phone#: ( 510 ) 235-1393 <br /> ! Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Title: Signature: Date <br /> . wrrwrarH#H//r raaMarraaraba/attar rrwrr«w#grrarq#HrMgrary#/arrrrgraM r4##tarp«+;r Kaa raa Hittrarrr <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> j accepting tank and/or piping. <br /> i <br /> Facility Name: E.C.I. <br /> i <br /> Address: 2S5 PARR BLVD. City:RICHMOND Zip: 94801 <br /> Phone#: ( 510 ) 235-1393 <br /> iDate Tank Received: <br /> Name: Title: Signature: Date <br /> •aaraaarrarataarrrraraaarraara+rrarraaaaraaraa+raaararrraararraaaraaraaaarraaasrarrara«arrrrrrrrrrrrararr <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> i <br />