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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .rrr.rrrrrrrrrrrrrrrrr.erre.r.rwrrrr.rrrrrr.»rrrrrrrrr.•rrrrr.».rrrrtrrrr++rrrrrr++r.rrtrrrrr•rrrrrrrrt+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: 2132 E. Mariposa Road, Stockton, Ca <br /> TANK ID #39 - Tank Description: 12,10 GALLON IIN, FAT)ET1 man, INF <br /> •rrr.rr rrrrrrrW. tree++rrrrr+tt tt•♦tstitfttttrrt++rrrrrrrrrrr.rrrr.rrr..rtrrrrrtrrrrrr♦rrr.rrrrrrrrrr+r+rr ' <br /> SECTION 2 - To be filled o4t by tank•re."I eontrano-r. <br /> Tank Removal Contractor: Vu._ �� t —IR 0- <br /> Address: � (v ` . '�.. �j ;iti)l I'1 City! �afVtotiik Zip: "t <br /> (I LG <br /> f. <br /> Phone #: 9 2 5 _3 L) Date Tank Removed: 17 November, 1997 <br /> ...rrr.rr....*...rrrrrrrrrr.rrrrrrrr...rrrr.......r.rr»*rrrrrrr.rr.r.rrrr»+».err rr..rr•rrr....rrrrrrrrrr+rr <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Am; H(1Ri TT7FI 1 TV <br /> Address: P.O, Box 30331 City1STOCKTON,CA z1p: 95213 <br /> Phone #: ( 209 ) 943 7793 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner. <br /> Signature: �� 4) Title:f8nrror R <br /> rrr.»rrrr�Y4rtrstsss4sYtt Hrr YrYirtr4.r Yt4r+rrrs Ytt4rrrrrr44trrrt++rsist+YYrttf4rYts4t4rr++sstss4YYrti tis <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: [Ai rnACT MFr TNr <br /> Address: P,O, Box 1864 City:TURLOCK, CA zip: 95381 <br /> Phone #: 2( 09 ) 668 9378 <br /> Date Tank Receiv ;" 6-OCTOSE ,LM. I /�t)�J <br /> Signature: Title: <br /> ..........** .».rrr.....rrrrr+rttt+erre.»rt.+rrrrrrr.rrr.+»rrtt..rrrrrrr+rrrYrt44444rrrrrrrrrrrrr Ytrr+rt <br /> Ea 23 049 (Revised 7-10.92) Page 10 <br />