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:VR 06 '94 12:44 TO 12094640138 FROM Helmick/Lerner, Inc. T-574 P.01 <br /> Fmra R-IA-A) <br /> CM 0a. U( <br /> Dept. q((7 Phones <br /> F}Ra Vt J F.ad <br /> DMERGROUM STORAGE TANK DISPOSMON TRACKING RECORD <br /> r.ggsruraa•aw•a•aertr•air•taiarat•......y►Yat.......patitr••Nssaq►sassNNtanggas•asqrqsrslaat <br /> SECTION l -Public Health Serviws Tracldug Shea wilt wmMpM each lank of lzed with its site MentiGcatton number. <br /> The Tracking Sheet b to be returned to Public Health Srtices wltirin 39 deva of acoeptaace of the tank by the d4posat or <br /> ret3cring facility. The permit holder is reapocubte for ensuring that that form k completed and retwao& <br /> FACI[1TYNAh� Don Avenue Pump Station <br /> FACII.TPY ADDRESS�7 (� 1 Don Avenue Stockton Ca. <br /> TAMC iD;R39- I O T ! `Q l Tank Dexription: 550 L11 rl L ac 1� <br /> a HttN.tq•Nq..ittYtt Yt.lt.r•Y..rir....tatYYttt pN•Nae eggs•••!f••••!t•lisp t area t arlgY q•NN Nq• <br /> SWnON 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor Helmick & Lerner Inc. <br /> Address: 3750 Auburn Blvd. City; Sac / Zip: 95821 <br /> Phone : ( 916 1 485-7222 Date Tank Removed: <br /> .aq•rslgtl.••NNNgto•ar•••s.N.NNSN►s.•N.•NN.r.r.aggsltsga.q.r....N.......Na.Naga...... <br /> SECTION 3-To be tilled out by contractor"decontaminating teak': <br /> Tank Decontamination Contractor Helmick & Lerner Inc, <br /> Address 37r,(L A��hurn R1vd. City: tae Zip: 45821 <br /> Phone#:( Qlfi ) 485-722 <br /> Authorized representative of eoutractor certifying thmagh signature below that the tank has been decontaminated to an <br /> approvod manner as required by Cat <br /> Sigoatura �� Title:_ Operations Manager <br /> atitl ease Yl..q q•a q q qqq Y!•q.lgYN.aatiYq•Naqua•q•aq•q•H t•.r N q.N.NNNN•■ggHa YgtNaa <br /> SECTION 4-To be signed and dated by an authorised representative of the treatment,storage,or disposal &cIIity <br /> aceopting tank andMr piping. <br /> Facility Name: Cal Coast Tank <br /> Address 424 5. Tenger city. Turlock Zip; 95381 <br /> Phone t*: f 209 1 �fi8-1378 <br /> Date Tank Receive&. <br /> t ' c <br /> Signature: Title <br /> - t <br /> +aN�ia+Nrq!l...taiNi.r a.•Nrtaaa Y•N.a.tib•f•gerraNa.ta ry..aaaaaagNatNasai ataaH aarq aaagYY <br /> M 23 049 (Revised 7.10.91) page 10 <br />