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SAN*76AQUIN COUNTY PUBLIC HEALTH SEAOKCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •#artrrara.a##wrrrrrrr►►artrrrarrrwMirirrrartrtrrra►+ririrMMMsrM+rrr#►rrMrrra#►r#rrrrrrrarrirarrrr►ra#rrarrrarr <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, <br /> � STOCKTON CALIFORNIA 95203 <br /> TANK ID q39 - ` 55 fftr <br /> TANK SIZE:F0T `-r-i PREVIOUS TANK CONTENTS: Dil Sri <br /> r##raw.rrM.tri.rrarrurrrrrarwrrrr+ryrrrrrrrrrrrrrrrria►r#►rarrrrrrrr+rrrrirrrrr.r+rrrrrwarrir►rwr+rr+rrr <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> JAMES J. HOBLITZELL <br /> Tank Removal Contractor: <br /> Address: BOX 30331 Cin,, STOCKTON,CA Zip: 95213-0331 <br /> Phone N: (_209 ) 943 7793 Date Tank Removed: <br /> vrrr....•.rMrw#wa#rrrrrrtwyrr.Mrrtirrri#rarM.r.rrrtrrrrrrtrrrrgrMr#rrwwww+rwrtrrrrrrrrrrrr#rrrr►rrrrrr.rwrrrir <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: SAME AS SECTION 2 DIRECTLY ABOVE <br /> Address: City: Zip: <br /> Phone M: (� <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner <br /> Name: Title: Signature: Dam tV ul2v <br /> .MMrrrrrrr.rrrrrartrr►�artrrrirrrrtrrrMra►rrMirrrM#rrrr+rrrrrq+rrrrarrrar►rNr+ ra rrrr+rrr►grrarrrr►rrrr <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: g53R1 <br /> Phone N: ( L09 ) 668 9378 <br /> Date Tank Received: Z /� �L <br /> Name: /1`�I S ISI Title: _Signa Date 12 <br /> rr#.....................#rti##rMr+rrr#rr#rrrr.aarrrMM#rrr►irr +rrarrrMrir+r r#tri►r+rtr#rrr#►#rrr►+►rr#rMrtr <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />