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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #ilii Mi tit#lrft#�##fill!##trriiyff#t!i!t*ii##/t#/tf#tt/t/!*/t#ittiiibit*/illi#y#*#!ilii###t#ti#y bitsti#ltsf <br /> SECTION t - 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 davs 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: NnNF <br /> FACILITY ADDRESS: 3507 �TFVTNSCIN STRFFT STnrk7m-- CA 99225 <br /> TANK ID #39 - i 12 C) — Tank Description: _ 500 (-,Ai I oN (FST). GASt1LT NF <br /> #slssiststttitii#ittatsy*f!s#t//sitsititysl*tilt#!ritystl#yttilsl**rrr*rlss/rii*sttit*itis*i*stiriit/rris#i <br /> SECTION 2 - To be fiiledout b tank removal contractor: <br /> Tank Removal Contractor: <br /> Address X 1257 City. Zip: 95201 -- <br /> Phone #: t 209 463 7108 _ Date Tank Removed: <br /> i****t*by**t*****t*y**ltrti/iii lilttilt#yiylitt**tttit*ttytitt trtr*#tr//*#t#tri ililt*iiitlif ilft*ttls*i*tt* <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: FALcoN ENERGY <br /> Address: P-0, Box 1257 City: STocmN. CA Zip: 95201 <br /> Phone #: ( 209 ) 463 7 .08 <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 /> #ii#iltlstyt*hittltt#ill#s/ri!**till*tsfit*t tt 11 tt#titrirtlrsttitiii#Mit#lysiss**#tf tf!ltrt*rrsss►*iissr/s <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 /> Facilitv Name: THE LEARNER COMPANY <br /> Address: 2700 NAVY DRIVE City: STOCKTON, CA zip: 95203 <br /> Phone #: 20c g } 9+83498 <br /> Date Tank Received: <br /> Signature: Title: WEIGHMASTER <br /> ti}Rffill*##tr**ftfi*ltirrri#*slifls itis!*fti#rlti##■**#li!ll itiii*#/iii ity#*tit###**#ltf*itf it###***i** <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />