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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ••••tttrttttt•rt••,t♦urr••rrttr••rrttrrr••t•••„r,,,r•rrtrrrtt•tri,•••t••rttrtrrgrttrttrttttttpttttttrt• SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form Is completed and returned. FACIL=NAME: Farmington Fire Dept. FACILITY ADDRESS: 25474 E. Hwy 4. Farmington, CA 95230 TANK ID #39- oP 3 I 10 "-D Tank Description:J50 gal lone diesel tank •ttrtt•tit.tit♦ttr„rrtrrrttr••r„t••u•u•r•r,,,•••••••••tt•••r,•try,•rrrt•,rrrrr,�r,rrtrr„r„•rtrttrrtt• SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor. Paydirt Excavating Co. Inc. Address: 269 Oregon St. City- Ripon Zip: 95366 Phone #: ( 209 ) 599-2347 Date Tank Removed: a•a..rt,•tit..rrr.rrrt..r.at.r•ra.rr.r.•t•tra.•tot.rttt.•....•...•••t••,..,••,.ar...•.•.•t••r.aat• SECPION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: pavdirt Excavating Co- Tnr_ Address: 269 Orego•,St. City:Ripon 7Ap:95366 Phone #: 2( O9 1 599-2347 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Signature: Title: •ttttttttttt,•tttt•♦ttttt•tttttrtrrtt•ttrrttttttttt•R•trttttttttttttttttrtrtttrttrttrttrtrrttrtt••rtttttttt SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: Cal Coast Mfg. Address: P.O. Box 1864 City: Tnrlrnk Zip: 95461 Phone #: (209 ) 668-9278 Date Tank Received: Signature: Title: .•ttt•„rtr•at....r........crit•uprt•t»•••r,,,,,,,r•r•,rurrrr,rrr,rrrtru rrtttrrrtr u•tttrt•trrtt,• EN 23 049 ' (Itevlsed 7-10-92) Page 10