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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD
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<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: 2132 E. Mariposa Road, Stockton, Ca
<br /> TANK ID #39 - Tank Description: 12,000 GALLON, N Ann ,AS01 I NF
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<br /> SECTION 2 - To be filled ogt by tank•r�^val contrarror;
<br /> Tank Removal Contractor:
<br /> Address: l . -.N 1�J j�-� City Zip: V6
<br /> Phone #: (2i U?/Z- 56A 3 t Date Tank Removed: 17 November, 1997
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<br /> SECTION 3 - To be filled out by contractor "decontaminating tank':
<br /> Tank Decontamination Contractor: AMFS NORI =F1 1 0 TV
<br /> Address: M. Box 30331 city. STOCKTON,CA 710: 95213
<br /> Phone #: 2Y O9 I 943 7793
<br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an
<br /> approved manner.
<br /> Signature: _ 1 �O r �3 Title:CC)n,TDArTno
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<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 rPACT MFr,- TNr
<br /> Address: P,O, Box 1864 City:TURLOCK, CA zip: 95381
<br /> Phone #: 209 668 9378
<br /> Dale Tank R iv ��7 �
<br /> Signature: Title:
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<br /> EH 23 049 (Revised 7-10-92) Page 10
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