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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> sasss»;safe:sif»»s;Ysiasaiiiais;saiiis;sssfa:sifisa;sssaa:ssaasfaasi;sisifs;sassaiissiifissass;fiYssa::fs»s <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 daps 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 /> TANKID #39 - �5( G Tank Description: 16 e,<f) C -e.--- Q t5 <br /> stat Nfa i#i7Yai Tfifi�ii�i'�i�i;if of ai is#fiYYa»fYaf;;Y;iifiafsif##;#ff»fY;itiff#iiiY#i;#;»ii ii it;ii#it itis <br /> SECTION Z - To be filled out b tank removal contractor. <br /> Tank Removal Contractor. Eli to IV Contractors Inc. <br /> Address: 2736 Teepee Drive City. Stockton, Ca Zip: 95205 <br /> Phone #: 2( 09 ) 461 6337 Date Tank Removed: <br /> aE.CTION 3 - To be filled out by contractor 'decontaminating tank": <br /> Tank Decontamination Contractor. same as Section # 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: , <br /> Title: ��!� <br /> iiiiatYfi#fi#ii Yiiifi;;iiiiiiiff iifiai'aiY#ff»#fYif#iYiYiii;iYiYi;;ii###Viii#iaYYi;lass Y#iYi#Y#sif sisals#iii <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 ) 634 9026 <br /> Date Tank Received- _ <br /> r— <br /> ¢nature• i Title: <br /> a;taiYYYY:: iYfaass##:iris»Y;fYs:a::ai:;#:iffi#sass;aYYi;sif:;ifYf;f aYsaf Yasf:#iiYf;ifaY;falai;;alalia <br /> E4 23 049 (Revised 7-10-92) Page I j <br />