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SAN AQUIN COI)NI-Y PUBLIC 11EAL Il. � ,C VIS <br /> ENVIRONNI[-NTAL HEALTH DIVISION <br /> CORD <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING: RI*, <br /> 11 <br /> any each <br /> SECTION I - Public Health Services Environmental Health <br /> b`inion Tank Public Health Sg Sheet ervices Environmental onmentalkli althtDivtisionli <br /> Tracking Sheet is <br /> ha <br /> atibn number. The Tank g responsible for ensuring that <br /> its site identification holder is <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit o <br /> this form is completed and returned. <br /> FACILITY NAME: F <br /> FACILITY ADDRESS: 730 E. Ch nn <br /> TANK ID #39 - TANK SIZE: 1 000 PREVIOUS TANK CONTENTS: Unknown <br /> SECTION 2 -To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Oil Equipment Service <br /> CitySan Andreas Zip: 95249 <br /> Address: P.O. Box 950 <br /> Phone #. ( 209 ) 754-1808 Date Tank Removed: <br /> SECTION 3 - To be tilled out by contractor "decontaminating tank": <br /> Tank: Decontamination Contractor: Oil Equipment Service <br /> Cit An Zip: 2 <br /> Address: <br /> P.O. Box 950 y n <br /> Phone#: ( 209 ) 754-1808 <br /> Authorized representative of contractor certifying through signature below that the tank has.been decootaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Keith A. Tallia Title: Pres . _ <br /> Signat e: ll Date <br /> i h Taia <br /> #4�0� <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 Nante: West Coast Equipment <br /> — <br /> Address: P.O. Box 2368 City: Turlock Zip: 95381� - <br /> Phone#: ( 209 ) 668-9378 <br /> Date fTankeceivvd: �iNamTitle: Owner Signature: aa- ista <br /> EH 23 046 (P.c%,kcd og/13/99) Paoe 10 <br />