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N." ..OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <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 />FACILITY NAME: A. Teichert & Son. Inc. <br />FACILITY ADDRESS: 103 North E Street Stockton, CA 95205 <br />TANK ID N39 - 1555-7 TANK SIZE: 1 , 000 PREVIOUS TANK CONTENTS: Waste Oil <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />Address: <br />Phone H: <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination <br />Address: <br />Phone !f: ( ) <br />City: Zip: <br />City: <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 <br />Signature: <br />*********************************************************************************************************** <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: <br />Phone N: ( )_ <br />Date Tank Received: <br />Name: <br />Title: <br />EH 23 046 (Revised 08/13/99) Page 10 <br />City: <br />Zip: <br />