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SAN JO QUIN COUNTY PUBLIC HEALTH SERVILIS <br /> ENVIRONMENTAL HEALTH DMSION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 - 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 /> FACILITYNAME: A. Teichert & Son Inc. <br /> FACILITY ADDRESS: 103 North E Street Stockton CA 95205 <br /> TANK ID#39 - /5, 5 — TANK SIZE: 20 , 000 PREVIOUS TANK CONTENTS: Diesel <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City: Zip: <br /> Phone #: ( ) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: ( ) <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. <br /> Name: Title: Signature: Date <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone #: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> +++##+rt#s#rssrs#s#rt#ss#rtrt+rs#+rt+*####*#####rtrt#+rt#s#ss#rt#s#s++++rt++#rt#rtrt+s##++#rt#++rt+r#sssssrtrtsss:s*#s*+#+ <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />