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l <br /> SAN JO1l gUIN COUNTY PUBLIC BRALTII SERVIZ'I s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> •}#N##Nr+trrlrlHr r1+##+♦r1#rrrr}+rtM+HrINNMNNrt rar#NMtHHIrarNa►►►►pNN///►N///N////►/►/I <br /> SECTION 1 - public Ilenidt Services Envlronnienlni Health Division Tank Tracking Sheet shall accompany each lank effiaed <br /> with Its she Identification number. the Tank "Tracking Sheet is in be returned to Public Health Services Environmental Health <br /> Division nllliln 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring dint this torn Is completed and returned. <br /> rACILIrY NAME: Hutchins Street Square E.P.A. N CAC 001239520 <br /> rACILO Y ADDRESS: 121 S. Hutchins Street, Lodi, CA 95240 <br /> 6,000 gallo "fit) 12 <br /> I ANK ID A39 - TANK SIZE: `W VIOUS TA K CONTENTS: 114 bunker oil <br /> 6+++A#r64}a#•+A}!+#t#r+lrr}rrrl#t!}♦••••rrrr•••#++!!!#rrrr}rrf!l+trrraarrarr}AA+}rrrr•+4rrrr}r#f}rrr#rrrrra <br /> 5F.C1ION 2 - To be filled out by lank removal contractor: <br /> fnnk Removal Contractor: Jittt 11101'pe 011, Inc <br /> Address: 351 N Beckman Rd./P.O. Box 357 City: ,L-odir CA Zip: 95241-0357 <br /> phone k': f 209 1 368-6175 Date Tank Removed:_ <br /> ,#+Aa>a•aa•raar}a}}rrrrrrrrtt♦r+rrrrrrrlrrrrrrrrr!#rrrrrrrr}r•rrrrrr•r}r}!♦}rrr}rrrrrrrrt}rrrrrrrrrrarrarra <br /> SECTION 3 - To be filled am by contractor "decontaminating tank": <br /> fnnk Decmrmmination Contractor: <br /> Addies: City: __ ZIP.— <br /> Phone /: -_-- <br /> Anlhntitrd trprernladve of contractor certifying Ihrongh signature below that the fnnk has been decontaminated In an approved <br /> nmmler m required by Cal EPA. <br /> Name: Title: Signature: Dale <br /> }# #r!►r ♦ A+ ••rrrr a}rrrr.•}}}r# r r! + r♦ A A rralrr rN Mraaa# <br /> ,57 <br /> -,1111mmTi 10 be signedligned And dated by an antioilied representa re o l e reatment, sto ag , at disposalec y <br /> accepting tank arid/at piping. <br /> Americlean, Inc. <br /> rncilily Name: <br /> Addteas: 2570 Almond Dr. , Lily,Silver Springs, y 89429 <br /> phone N: 800 ) ,471-2105 P <br /> Onle 1 ank Received: <br /> lanneju _Title: p o 4 �.. Signamre• Data r/ <br /> 'rA}aA}r}}#ttrtalrrr}ArrAr}}}Af}}4rrrrrrr4+t#A♦r•rrrlrrrrrr#Frrrrrrr}}♦rrr rrrrrraararaaaaraaararrNaaaa♦ . <br /> :1123 046 (Revised 9/11/96) Page 10 <br /> I <br /> 1 <br />