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SAN J __QUIN COUNTY PUBLIC HEALTH SER` ES <br /> VIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND-�TORAGE TANK DISPOSITION TRACK, .G RECORD <br /> •........w........*w.......... iwtwzwziriF.rrs.iww4.srssaYrrR.........*......**...*.....i*..*....s.......szi <br /> SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: A. Teichert & Son, Inc. <br /> FACILITY ADDRESS: 103 North E Street Stockton, CA 95205 <br /> TANK 113 #39 - 555. TANK SIZE: 20, 000 PREVIOUS TANK CONTENTS: Diesel <br /> I....................rwlrl.s.I........rtwwa!!..........llr..l..r.F..wi.F..FY...wrtr.rr..rww>.........r....... <br /> SECTION I - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Town & Country <br /> .address: 3373 Luyung Drive City: Rancho Zip: 95742 <br /> Cordova <br /> Phone 4: (9 16.--) 636-9500 Date Tank Removed: March 23 , 1999 <br /> ..........a.....i....*............r....i.r....rsts.........r..r...........w.w.....FY.v...........1.......... <br /> SECTION 3 - To be Filled out by contractor "decontaminating tank': <br /> Tank Decontamination Contractor: Philip Services Corp. <br /> .Address: 395 West Channel Road City: Benicia Zip: 94510 <br /> Phone 4: ( 707 ) 746-8287 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA.#yN/ r �j <br /> Name: ROQ" V. 6Title: UOU-/-XQjAa,7—Signamre: Date /Z <br /> w.lr.rw.r..rF.r....1.Mr.rirrlr.ai!l.....ls...sr.rt!!.!!!rtl.rt!!rlitr...........w.rirrrlrr!!lrtw.r.!!lrrrlriF.F <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accenting tank and/or piping. <br /> Facility Name: Triangle Inc. Of Sacramento <br /> Address: 3525 52nd Avenue Cary: Sacramento Zip: 95823 <br /> Phone 4: ( 916 ) 421-1990 <br /> Date Tank Received: March 23, 1999 O p <br /> Name: Nick Chronis Tide: President Sig ff are 2 3 I I <br /> ....zF....................l..r..wY..........F.F.si........Y...i .. ...:........r.l.........sz......... <br /> EH 23 04b i Revised 10119198) Page 10 <br />