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SANwOAQUIN COUNTY PUBLIC HEALTH SLICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *rtwwwrtrtwr#rtrtwrtwtrrstri*++wwwrtrt*kwrW#++++++w#wWrtw+rwrwr*#iwW#irww#*#+rtr#w#r#r+irr##k+#*www►#W#wwwrt##ik«+#►rt <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: FOWLER'S <br /> FACILITY ADDRESS: 405 N. EDISON STREET, STOCKTON CALIFORNIA 95203 <br /> TANK ID#39 - TANK SIZE: PREVIOUS TANK CONTENTS: l�L CS GL <br /> rt*«wWWw#r#r#rrt#WrrkriwwwwW#trkrtwwwfrtWwwr#iiiwwwitiwrtrWRri#witri+w«rWW*w+w##r#«+rrrtrtwwrriiiwrrWrtirrrirtwrkrtr# <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> JAMES J. HOBLITZELL <br /> Tank Removal Contractor: <br /> Address: BOX 30331 City: STOCKTON,CA Zip. 95213-0331 <br /> Phone N: ( 209 ) 943 7793 Date Tank Removed: <br /> twrrr#ri#rtwwrrrrkwwwrWiiw+wwkr*k+rww+rtr+wrw###tr#►kiwwr#irrtwWrr##rttr**w+ww#r#+w#rk+wrrrtrwgr++#rk«wkrrtw#kwr <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SAt E AS SECTION 2 DIRECTLY ABOVE <br /> Address: City: Zip: <br /> Phone p: <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 /> rt#wwwtrrrrwwwwt#wwwrrWiirtirwWr#wrtwwr#riprWr*wwrWrrrww#Wr►iwwwWrtwwrrwrtr#kwwwwr#rw##rwaWWiwwrriW#wirri+r#* <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: WEST COAST EQUIPMENT <br /> Address: BOX 2368 City:TURLOCK,CA Zip: gs-iRt <br /> phone#: ( 209 ) 668 9378 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> #rrirwwwrkrrtwrkrtwrrrWrtwwwWWik*ww+wwrwrwiri«wWr►rrwrr*iirtw#riWrtww#rrtrww#irwi►rtwrk«wrwrtrtrriwt#rtwirrwr#iwr#i <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />