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SAN JOAQUIN LOCAL HEALTH DISTRICT UNDERGROUND TANK DISPOSITION TRACKING RECORD x x x x x x xxx x x xxx x x x x x x x x x x x x x x x x x x x x x SECTION 1 - The San Joaquin Local Health District's Tracking Sheet Will accompany each tank affixed With its site identification number. The Tracking Sheet is to be returned to San Joaquin Local Health District Within 30 days of acceptance of the tank by disposal or recycling facility. The holder of the permit With number noted above is responsible for ensuring that this form is completed and returned. FACILITY NAME: 7-11 FACILITY ADDRESS: 455 W. Grant Line Rd. , Tracy CA TANK ID #39- -_ x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Petro-Check, Inc. Address: 271 Opportunity St. , Suite C Phone # (916) 927-8155 Sacramento, CA Zip 95838 Date Tank Removed x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x xxx x SECTION 3 - To be filled out by contractor "decontaminating tank": Tank "Decontamination" Contractor Petro-Check , Inc . Address 271 Opportunity St. Ste. C phone# (916) 927-8155 _Sacramento, CA Zip 95838 Authorized representative of contractor certifies by signing below that the tank has been decontaminated in an approved manner as may be regulated by Department of Health Services. SIGNATURE AND TITLE xxxxxxxxxxxxxxxx * xttxxxxxxxxxxxxxxx SECTION 4 - To be filled out and signed by an authorized representative of the treatment, storage, or disposal facility accepting tank. Facility Name Refinery Services, Inc. Address 13331 North Highway 33 Phone# (800) 874-4444 or (209)892-674 Patterson, CA Zip 95363 Date Tank Received AUTHORIZED SIGNATURE AND TITLE x x x x x x x x xxx x x x x x xxx x xxx x x x x x x x x x x x x MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. SAN JOAQUIN LOCAL HEALTH DISTRICT ATTN: UNDERGROUND TANK PROGRAM P.O. BOX 2009 STOCKTON, CA 95201