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THERE WILL BE THREE (3) FORMS, ONE FOR EACH TANK. UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD ,,,uus•a,♦••••suuuuauuu•,suraar•ru„♦•„•s•,raaurrrrssuaaa•,rusuuusu„uruusu•u•uru SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: CUSTOM RV 4807 S. AIRPORT WAY, STOCKTON, CA 95206 FACILITY ADDRESS: TANK ED #39 - - Tank Description: 12,000 gal, 2,000 gal, 1,000 gal ♦.,....,,a..•..••.....,srrruuusauu,u•a•••u•••a,uurruuaaaruu•s•arr•••arurruu,uuu••ssua• SECTION 2 - To be filled out by tank removal contractor. Tank Removal Contractor. WESTERN METER SERVICE, INC. Address: 2735 TEEPEE DR. , STE. E City: Zip:STOCKTON 95205 Phone #: ( 209 ) 948-6124 Date Tank Removed: ..a.asa•a••,ruuauau•••u•s•usua•,uuararu•••♦sra raarr••••sru,uua,•rsrrrua•u,s•,u••uuusuu SECTION 3 - To be filled out by contractor 'decontaminating tank': Tank Decontamination Contractor: REFER: SECTION 2, ABOVE Address: City: Zip: Phone #: (� Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: 1ACK R. DE "ITT Title: SALES MGR. aru•ru,u,••arrur•••su•a♦••urusuuuurru•,suruusu♦uararuuuuuuuu••uurrrrrus,u•uu SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: CAL—COAST MFG. CO Address: 242 TAGNAR ROAD City: TURLOCK Zip: 95380 Phone #: ( 209 1 668-9378 Date Tank Received: Signature: Title: •ausss•carr•uss•,asrr••s•ss•ruruss,•srasaus•s•sus,,uaus,ruu„uaa,uuaas•ussrrr♦•,urr•s••sa ER 23 049 (Revised 7-10-92) Paye 10