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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number.
<br /> The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or
<br /> recycling facility. The permit holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: Don Avenue Pump Station
<br /> FACILITY ADDRESS: Don Avenue Stockton Ca.
<br /> TANK ID #39 - l _ Tank Description: 550
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<br /> SECTION 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 ) 485-7222 Date Tank Removed:
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<br /> SECTION 3 - To be filled out by contractor 'decontaminating tank':
<br /> Tank Decontamination Contractor. Helmick & Lerner Inc.
<br /> Address: 375(1 Auhurn Rlvd. City: Sac Zip: 95821
<br /> Phone #: ( 91_6 ) 485-7222
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner as required by Cal EPA../
<br /> Signature: Title: Operations Manager
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<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: Cal Coast Tank
<br /> Address: 424 S. Tenger City: Turlock Zip: 95381
<br /> Phone #: 2( 09 ) 668-9378
<br /> Date Tank Received:
<br /> Signature: Title:
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<br /> ER 23 049 (Revised 7.10.92) Page 10
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