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'THERE WILL BE THREE (3) FORMS, ONE FOR EACH TANK. <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> t,tisaH rttf,f,,ttraarrt,art•aarraauta rf•matt,taert•ua,tttu•ttatrtruaat•aurraar•autrr <br /> �f <br /> ECTION 1 Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. ±� <br /> e Tia�kIng.Sheet k to returned to Public Health Services within 30 dere Of aacptance of the tank by the disposal or <br /> ecyclf g facility. -The peimit holder is responsible <br /> for ensuring that this form E completed and returned. <br /> At,q,t'I'Y.NAM <br /> E: _ -CUSTOM RY. - <br /> -: -- 4807 S.—AIRPORT WAY, STOCKTON, CA 95206 <br /> ACILPI'Y ADDRESS:_ - <br /> - - Description:---_ 1 , 7 000 :� i �-]-,-F 1 <br /> +.Nr ID #39 �0 �.__ tm� -�' - <br /> •sept•tu•, i...,,,..a.r..a....a.a•......ata....aura araar•tarar•ar•at•r•a•a•a t•.......lrf <br /> ESI ION 2 - To,be filled out by:tank removal contractor. <br /> I <br /> ank Removal Contractor. WESTERN METER SERVICE, INC. <br /> 2735 TEEPEE DR. , STE. E STOCKTON 95205 <br /> ddress: City: Zip: <br /> s-. <br /> 209 ) 948-6124 Date Tank Removed:_ <br /> a•atca,,tattr y•,ott•rat,ttatatruatarr,rf•t+„•rrrtrrr•ttrfuareaataaf a•utaar,taatar••. 5. . <br /> ECTION 9 - To be filled out by contractor 'decontaminating tank': <br /> Tank REFER: SECTION 2, ABOVE <br /> Decontamination Contractor: <br /> Address h i� City: 71p: <br /> Phon6 #: � — <br /> Authorized,representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> pPirn'ed �”"er as,requited by (al EPA �� <br /> I ..' I � Title: SALES MGR. <br /> �,to ratattti� tattt,raHtt•ttNttf at,a,aaatrgra attlaataaratttataa araa•t tl,a Hrlr•fft,tt <br /> ;8r(-,FtON d - To be sipcd and dated by an authorized representative of the treatment,storage, or disposal facility <br /> accepting tank and/or piping• <br /> `^Fadllrr Name: CAL-COAST MFG.•. CO <br /> TURLOCK 95380 <br /> x242 TAGNAft-RAAB 4 ? <br /> City: Zip: <br /> t.A4rL-ss <br /> 209. 668-9378 I , <br /> h6,_Tank Recely — -------- ---- <br /> a_ - Title: n n <br /> 1� <br /> a'Rtt'ttt•ttttrtt•ils'*a,r•r•♦ett•ttaea•tt•>•trt•a.....rtae r•t,aaa•• <br /> a <br /> _23:.' - evfeed 7-40 92) ____.. Page 10 <br /> t <br />