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M <br /> r THERE WILL BE THREE (3) .FORMS, ONE FOR EACHI'ANK. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> Nva Hti••Nur•r••tffi Nttl••.•rsas!>!•t>rN•r•>NtrNNfNNaN•>N rN>Nfi•Nai••rs>.•s••fatN...e <br /> ON L- Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. <br /> Tracktip Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br /> rerycilrg facility. Me.pemilt holder is responsible for ensuring that this form is completed and returned. <br /> FACILITY-NAME: __ CUS-TOM._t3V . . . _. - <br /> 4807 S. AIRPORT WAY, STOCKTON, CA 95206 <br /> _-FACT <br /> ,ITY ADDRESS: - -'I';S -- <br /> �- - o nwi�.�Y ID #39 - � D� ?�" :ank Description: 4�-�- l 2,000 qaI, -- <br /> vNtfa .tatrl>9ttttt.Ht>tN•>NH>Nf••Nar 11NV H••NHHff••NN•tr�ee••e•NaNtee l-A•H>iN tNtHN••••>• ;. <br /> SE-C Ii N 2 • To be Gilled out by tank removal contractor. � <br /> Tank Removal Contractor WESTERN METER SERVICE, INC. _ _- <br /> 2735 TEEPEE DR. , STE. E STCCKTON 95205 <br /> =ddre� : City: tiP: <br /> hone (_209 1 ---948-6124_ Date Tank Removed: <br /> 1PSS NnN ttttrrNfNNfNttataNNHt Nfttt•tlrN>tff Nf NiNNtH>NNtr HtlNf itNNU NiaftN•tNf•Na• <br /> I <br /> ECTION 3 - To be filled out by contractor 'decontaminating tank': REFER: SECTION 2, ABOVE <br /> nk. Decotamination Contractor.If City. tiP <br /> dress: <br /> ,' 'k i <br /> f il6nc <br /> i <br /> athonzai"representative of contractor certifying through signature below that the tank has been decontaminated to an f <br /> ppiovc4 manner as required.by Cal EPA <br /> TiUe: SALES MGR. <br /> ��lgn <br /> ., h;_��ir0ee♦ON'Haq •ttUNNlr ttrtttrtflttt>HttrlitttrfrtlrftN•i>♦a>ttit•NttN>NN•>tNNiNNtNi•f Nff Ni• <br /> �„ • T� w sig Cd and dated b an authorized representative of the treatment, storage, or disposal facility I <br /> accepting tank and/or piping, <br /> :ac lity Name CAL-COAST MFG. CO <br /> -242-TAGN&R--ROAD- /J.� %, b�y`c� TURLOCK Zi 95380 <br /> pcdre s: / Gty. P <br /> w bode .,f 209 ) 668-9378 <br /> ata Tank <br /> I r - V� — Title: <br /> �QCly BNar •rrt6 :910a>.e9Vt•i>t�rattrtlPf rtf to♦Yreee>t>itle•>e•ifftlt F7f•>••H>af r<t!•f•a e.rr••rl Nit•.t• <br /> Peg* <br /> (Pevlcrvd 7-iu-M <br /> 70 <br /> r <br />