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UNDERGROUND STORAGE TANK DISPOSITION TRACIONG RECORD <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 - (-o3-03 Tank Description: <br /> siii#ii#####R####isiii##i#ii#R##Riffsisiiia#i##i##f##R#i#iRRR##fif###ifi#R#########Ri##fi#f#####Ri iiisiifif <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: E 1 i to IV Contractors Inc. <br /> Address: 2736 Teepee Drive City. Stockton, Ca Zip: 95205 <br /> Phone #: 2( 09 ) 461 6337 Date Tank Removed: <br /> iiRi#fis#sisis#f###iR#ii###fssssffff ssiiiiiif##f###ii#fRfi#Rffi#ff#iifs#ff#fi#f##i##Rf#ii##i##ffii#sf iiiffi <br /> SECTION 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 E A. <br /> Signature: Title: <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 /> Signature: Title: <br /> EH 23 049 (Revised 7-10-92) Page I <br />