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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ••ttritttsriiattstttrirrrtsttri++rttrtrrir++rr«risrttastrir«r«ttrtrtttsttii♦t++rsstttttsststst++s++++++»t• <br /> SECTION 1 - 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: USA PETROLEUM <br /> FACILITY ADDRESS: 213[ E. Mariposa Road, Stockton, Ca <br /> TANK ID #39 - 1669-04 Tank Description: _3,000 gal lgn duel <br /> tri+tiittiiiY rtitti++«rtttiit YYiittrtiiirttttitiriattiitiii++arrtiilrrttttiit+tttttttrrt+ttiirrtt«rt+tttt+t <br /> SECTION 2 - To be filled out by tank removal contraptor: <br /> Tank Removal Contractor: U5A Petroleum _ <br /> Address: <br /> 1261 E. Ninth Street City: Pomona, Ca Zip: 91766 <br /> Phone #: 800 622 5930 Date Tank Removed: 19 nTnnamhpr 1 997 <br /> •irttti++ttatr«irrr•urrri«•sssr++tartssiriaiirrtrt+ttrrirrtartritr«arw«rtrtttt+r««trttttsat♦++++ratttttttt <br /> SECTION 3 - To be filled out by contractor "decontaminating tank': <br /> � <br /> Tank Decontamination Contractor: MF4 i / <br /> UnRl Tun I v u <br /> Address: P.O. Box 30331 City_STOCKTON,CA z;p: 95213 <br /> Phone #: ( 20 ) 943 7793 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner. <br /> Signature: Title:�niTc <br /> itttiYYYtYtilitYititaritiiitttttrtrYttitsrr iraYia ittttriiitatrtriiYira YarrrriiiYtrtlttYtYYYf+ittttirttYrr <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: CAI I.nAST MFr,- Tnlr <br /> Address: P,O. Box 1864 City:TURLOCK, CA zip: 95381 <br /> Phone #: 2( 09 1 668 9378 <br /> Date Tank R ived: V <br /> Signature: — 6 Title:l <br /> tY+itisrYrir++stttsststissrssrsstrtrYii+rsisti+lass YrrYsaa Yrt YYia Ytstittrsts Yrrssstass»assssarsassrasts <br /> ER 23 049 (Revised 7-10-92) Page 10 <br />