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UNDERGROUND STORAGE TANK DISPOSMON TRACKING RECORD <br />.le to *to*** gtsl Nsss•sssletb sill oossprH N•••***ae s arso...sr.elllltsolrsrssr r• al• r• stools** e•••..•**oeo <br />UC ION I - Public Health Services Tracking Sheet will accompany each tank aMmod with Its site identification number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />rerydtng faclity. The permit bolder Is responsible for ensuring that this form is completed and ranrned. <br />FACILITY NAME CAL -TOAST TANK <br />FACamADDRESS: 424 J. TEGNER ROAD, TURLOCK, UA %381 <br />TANK ID #" - Tank Descriptloa: <br />•••♦rssrsrsssirs•*arusssss•ss*s.ria.us.s*se••sr.••s•s•s•s•ns.ssssesr•sir•ls•sesis..•ssrees.saess.sssr.• <br />SECTION 2 - To be filled out bi <br />Tank Removal Contractor: JAM <br />Adder box 30331 <br />Phone #: f 209 i 943 7793 <br />tankrGcI contractor. <br />S J, tMITZELL <br />Q STOCKTON 95Z13 <br />4 p <br />Date Tank Removed: <br />•.•..r••s•sssssr•ess..u•.••ssa.esss•••••seesrssss•s•ssr*esss•sssss•••err.1.•esssssr•s.sr•urresess►•esssa*e <br />SECTION 3 • To be CUM out by contractor -decontaminating utak': <br />Tank Decontamination Contractor .IAMFC .I. How IT7P1 i <br />Adder Box 30331 Mr. STOCKTON zip: 95213 <br />Pbone *:I 2091 943 /795 <br />Authorised representative of contractor certifying through signature below that the tank has been decontaminated In an <br />approved manner as required by Cal EPA <br />Signature: Tift <br />�a•�••••••.....•a••...•.s.♦l•rss nitses•sssrrtlulassras e...res*.sea••e•s•stssss••*•stsu.s***ssuslasss* <br />SECTION < - To be signed and dated by an sathaiied representative of the treatment, storage, or disposal facnity <br />accepting tank and/or piping, <br />Facility Name CAL -COAST TANK <br />Adder: 424 5- TEGNER City <br />phone s: f 209 1 668 9378 <br />Date Tank Revived: <br />TURLOCK <br />Signature: ,Dtl&- <br />Zip: 95381 <br />s•ssssess•saris.asrle••s•rs..sussstsss••••••s sessaa••..r.s.esssrrss...n.•rsss•ses s.ss•as•sl•sssr...•• <br />EN 23 049 (Revlted 7-10.92) Pan // <br />