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UNDERGROUND STORAGE TANK DISPOS177ON TRACKING RECORD <br />SECITON I - 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: M. C. Liquors <br />FACILITY ADDRESS: 1628 Harbor Rd. Stockton, CA 95203 <br />TANK ID 039 - �% i `t� Tank Description: 10,000 gallon <br />•p•••y••••••u•••••p•••r••••d•••••••••••rr••••••ur•••••••••••r•••r••••••H••r••�••r••••••••••N•HHH• <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. Paydirt Excavating Co. Inc. <br />Addrm: 269 Oregon St. qty; Ripon, 7J 95366 <br />P� <br />Phone*:( 2( 09 ) 599-2347 Date Tank Removed: <br />SEC [ON 3 - To be filled out by contractor'deeoniaminsting tank': <br />Tank Decontamination Contractor. Paydirt Excavating Co <br />Inc. <br />Address: 269 Oregon St. q Ripon <br />ty: Zip: 95366 <br />Phone N:( 209 1 599-2347 <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. <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 Mfg. <br />Address: 1540 Lynwood qty: Turlock Zip: _95380 <br />Phone N:( 209 I 668-9382 <br />Date Tank Received: <br />Signature: <br />EN 23 049 (Revleed 7-10.92) pass 10 <br />Title: <br />