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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> YtHYitt YitYaagiia iait Yt/tartlYri\i/irt;H/tr/\aaitt!\YYIHtYi;;ia;\ait\raaYt/;trltt\iM/r\\/at/!tY\rr\Yrt <br /> SECTION 1 - 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 /> C40 i51019 �6�b 1• <br /> TANK ID#39- _AggRfi• TANK SIZE:_ PREVIOUS TANK CONTENTS: YSEB Bib <br /> Ib HIIt I1tIt YtY lit/t/ilii\iiia YiltYtrrlrco/t/rra/fila;aar\/ai/r\a\ytr\tYtittYit/aatattlrtr YYtt\rYirrr Miri♦ <br /> SECTION 2 -To be filled out by tank removal ntractor: <br /> Tank Removal Contractor: MUSCO EXCAVATORS, INC. <br /> Address: 2526 GREENVALE COURT City: SANTA ROSA Zip: 954D1 <br /> Phone#: ( 707 ) 579-0250 Date Tank Removed: <br /> ...Y/au.........l......irrriuiisw\r.......r>/iitrail.iitliatrrtittrrtt/tt/i.itratarliwtiatti.ri\raia/raa <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: E.C.I. qRIC ry�opNNpp <br /> Address: 8889X%RRRNWXK9X9NNRR 255 PARR BLVD. City: SRDt� MSS Zip: 2SKOU 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: Dare <br /> ..................w.rwr.a../.writ/r/rtY.1/twi.rlisaat.....irwaataasai.rat/ttaititiirar\/tt/tt/\r/t\\\ttsat! <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> iaccepting tank and/or piping. <br /> Facility Name: E.C.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 /> trt;t;rt.sst;ttYt;tt\atrttYarr\rtuft...isr;♦ttr!\ttrsttrtrtr\t;;\\ttrs\\ssrttrssrYtrtt;;t:trrirt\rstrtatt <br /> EH 23 046 (Revised Og/13/99) Page 10 <br /> 1 <br />