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UNDERGROUND STORAGE TANK DISPOSMON MCiUNG RECORD <br />Iftltt•.tttt♦fall►ttttlatf•ttfa►•111•►•tttttt•Iaa•Ittl1•f•IIIIstlf lttltttf t►11l►•atilt/f••*11.•1*•I•*I*t•.1 <br />MCnON 1 - PtrbHC Health Services Tracking Sheet will accompany each tank aMwd with its site identtficatloa number. <br />The Tracking Sheet is to be returned to Public Health Services vdl!& 30 days of acceptance of the tank by the disposal or <br />re<ycHng fadtity. The pasta bolder Is responsible for easnrtag that Wk form Is completed and returned <br />FACILITY NAME: CAL -WAST TANK <br />FACHM ADDRESS: 424 J. TEGNER ROAD, TURLOCK, (-A %381 <br />TANK ID #39- Tank Description: <br />sans.GOO sa►t►ssltaaas$***sass*••aa.tlNH•N•.Hltt..laNNN•as s. t.•p N/t•tNIb Nt N.aNN *so* ***so* <br />SECTION 2 - To be filled out by tankrowel contractor. <br />Tank Removal Contractor. JAMES J . I10BLI TZELL <br />Address: box 30331 <br />Phone r: ( 209 1 943 7793 <br />ser.STOCKTON ti 95213 <br />Date Tank Removed: <br />..••••H•.st•HI.1/1•sUtH•tt•NNHHNtN NNaHN.a.IIs•/t/•/..HaNN•N•/11/••N/N HNNNtHItNN <br />'3EC"nON 3 - To be filied out by contractor decontaminating tanks: <br />Tank Decontamination Contractor JAMES J. HOBLITZELL _ <br />,�r.. Box 30331 aty STOCKTON ZIP. 95213 <br />Pbone r: ( 20% 943 /795 <br />Autborized reprtsentathv of contractor certifying through signature below that the tank has been decontaminated In an <br />approved manner as required by Cal F -PAL <br />signature; Tula <br />Ut•HI.NN•.•••NttN atltt•t•NINNt NisIN/HNt*•H•I•.HINtN tttNltt •t ttNt►IHtt•NNNtHItt Ha►t <br />SECTION < - To be signed and dated by an authorised representadve of the treatment, storage, or disposal facility <br />accepting tank andfor piping, <br />Faawky Nama CAL -COAST TANK <br />424 �, TEGNER <br />Phone #:( 209 1 668 9378 <br />ah„ TURLOCK Zip: <br />y5 81 <br />Date Tank Recelved <br />Sfgaature: <br />Title: <br />a►tttlatilt!st•ttlsNtt•ttN•tNNtslNNNftIHSNNNNt.1. NstN1.••NtlN is►•Ift 11/*NI/ttNtll••N• <br />10 V 049 (Revised 7-10-92) <br />Pant (Q <br />