REMOVAL 1995 - Laserfiche WebLink

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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: J & L Market FACILITYADDRESS: 8115 South E1Dorado Street, French Camp, California 95231 TANK ID #39 - Tank Description: =##is�Sf »iss #s»rias=iss/tsa�=s�sisf#assssasass=as=liii,sfii#s!=##=s»siis##,Y#af#»iff»lsis##iiia»:##is SECTION 2 - To be filled out b/tank./ removal contractor. Tank Removal Contractor- Elite IV Contractors Inc. Address: 2736 Teepee Drive City. Stockton, Ca zip: 95205 Phone #: 2( 09 ) 461 6337 Date Tank Removed: i»f iiiif if i»#»#ff#Y#fYfif»fY#iiiiiiiiili#Yiiif##i##iiiii#i##ii#»ii#ff#ii##iiiii!i»#i#i###»##»!iii It iii!!i aE,CTION 3 - To be filled out by contractor 'decontaminating tank": Tank Decontamination Contractor. same as Section # 2 Address: City. Zip: Phone #: ( Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA- Signature: — Title: !' =s:»is:ss»asis==a»iss#sassa#si#assists=:s=iss»i»»ai:s:i###s=s:arias#»slsssssisis#i:seas:tis#lsas#is:ss::::i SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping Facility Name: Cal Coast Tank Address: 424 S. Tegner Road City. Turlock, Ca Zip: 95381 Phone #: ( 209 ) 634 9026 Date Tank Receiv — ,nature: Tule: »»»ai=iaai ##i 1aiYYiYiiiiii#=,.iiia,.==aaa.#tails#i#aa.YYY#,.Y,»,Y=i»ii#f iii#i##i.Y=#a#Y.»as»#,#=#,## EH 23 049 (Revised 7-10-92) Page