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%Noe .,.W <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVHtONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION I- Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITYNAME: silveria Property <br /> FACILITY ADDRESS: 1933 Hiawatha Avenue stockton ca 95205 <br /> TANK ID#39- TANK SIZE: 500 PREVIOUS TANK CONTENTS: gasoline <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: advanced Geo Environmental inc <br /> Address: 837 shaw road City: stockton caZip: 95215 <br /> Phone#: ( 209 ) 467-1006 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: advanced geo enviornmental inc <br /> Address: 837 shave road Cinstockton ca <br /> gip: 95205 <br /> Phone#: ( 209 ) 467-1006 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: william little Title: geologist Signature: Date <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: west coast equipment inc <br /> Address: po box 2368 City: turlock ca Zip: 95381 <br /> Phone#: (209 ) 668-9328 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />