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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> iif iifff iitiiif Yf iiif iff iif if iffif ffffiif ifflfit tiitffffftftiftfltiifffif if iif#*f Yffii Yffif iifftif iifiiisas <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: J & L Market <br /> FACILITY ADDRESS: 8115 South E1 Dorado Street, French Camp, California 95231 <br /> TANK ID #39 - 1 SCc ` CD Tank Description: <br /> -„/ZL <br /> �###*/��� / ? <br /> a*YTiisif�ii## ��isa��t�s�lfif#ifsaiffff i##f**#iai#ffiii*fi#if#iii###***i#####*#i=#i*#####i##is###i#i=i <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Elite IV Contractors Inc. <br /> Address: 2736 Teepee Drive City; Stockton, Ca zip: 95205 <br /> Phone #: 2( 09 ) 461 6337 Date Tank Removed: <br /> afaaii#inti###*fi#ii##f###Yt*i#Ytiifiif iiiii#i!*#*fisc##*fiif#iii**ii#####ii#t#*#####i#ii#iii#t#iiiii iiif <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor: same as Section-u 2 <br /> Address: City: Zip: <br /> Phone #: ( <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: iX <br /> iaiii#if##*:#:ifiii#iiif*##:i#i::ii=====__=====iiif**===i#fiif#ltii**!f##f#iif***#ff*#if#f*ff##iif its:ilii! <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: Cal Coast Tank <br /> Address: 424 S. Tegner Road City. Turlock, Ca Zip: 95381 <br /> Phone #: ( 209 ) 6 026 <br /> Date Tank Received- <br /> ignature: Title: <br /> ifti#*:*##ii ifffiifi*#*#t#iifi#i========iiitilii*====___==#==Yifi#======sf:f#i#f**#fi#f if iiififl:iif iii <br /> EH 23 049 (Revised 7-10-92) Page <br />