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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> rr HrYir Yrrt••bra•ir>•r•fir/•r«H/rr•Yrr/r«//tr/H•t>Hr>.YHY»rrttbra•>rYat«>M>t>t>air•«r rYrritrr rY rr Yi <br /> SECTION I- Public Health Services Environmental 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: CHEVRON STATION <br /> FACILITY ADDRESS: 139 S. CENTER STREET <br /> DID :51D-7 <br /> TANK ID#39- '3M_1'r TANK SIZE: 10K PREVIOUS TANK CONTENTS: PREMIUM <br /> Y..a••...rrrba«r•«rtbtr•barar«b bb bbrrrbrbbt.bbtbbrrbbrrbbb•bbbbbrrr•b bbr>.ribt <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: MUSCO EXCAVATORS, INC. <br /> Address: 2526 GREENVALE COURT City: SNATA ROSA Zip: asam <br /> Phone#: ( 707 ) 979-n29n _ Date Tank Removed: <br /> ....bY.•...••..•bbri..r...r.•babbi./..br..........t..br...*0.... «b b...•tb. <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 /> ..agrr..arrua.bb««.....w.uaaa.wb Y.iwtvabb/.b/bbr/.abbsbwirrrb rH rtrrt r/r>•r Hrtbbbb>br« <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 /> i <br /> Facility Name: E.C.I. <br /> i <br /> Address: 255 PARR BLVD. City: RICHMOND Zip: 94801 <br /> Phone#: ( 510 ) 235-1393 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> »t•U>rbb>iirr•r Yis♦>Yri>>t b>t>br#i rt«ri/»r/Hb>r>tit>r>tri 4 Mfrs>bibgb•Yt>bi•tr•♦q>rpbbb <br /> EH 23 046 (Revised 08/13/99) Page 10 <br /> I <br /> I <br />