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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> if iffltffiiYif tiif fflf fiffif iii iiiffftiiisf if#Yf tiiifiiifif iffYf if#lffiff itffiiif itf iffitf iiilf iii•siiff#st <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 /> FACU-=ADDRESS: 8115 South E1Dorado Street, French Camp, California 95231 <br /> TANK ID #39 - i S(o.J- OZ- Tank Description: Z�C�D<i //nr� �G�� L4- `ori 5 <br /> ii tiiif#ffi#fffi#iiiftlisfffi####if tf tf iilii#tiff tiif if i!#i#i#f#ii#ii#iiiti#!#f#iiiii##i##ffi####!#i#it#### <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 /> i}i}iRf#iiYi#if#f#i##iiii##i#i##i#ii iff#!#if##}#f#iiiiili!#i!!i##fii#i#####}##i#!f#i##ii##iii}*}iifiif#i## <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 EPA <br /> r <br /> Signature: — Title: (/. <br /> iiiiii*ffif#iftisi iiif ii i!!i!ltiiii#ffi#f##ifif iiitf if!##ffiifffff!##i#ifs!#i#!!#!###fiiii#####f}#iiff#}ii# <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 /> ignature: Title: <br /> i}#fiffff##f ifffii#f}###}#}##fff ff itiitif if i#i###fff#ff#ffiifli#f##i!##*i#i*f#iY####i##fi!!i##!##!#ftfit <br /> EH 23 049 (Revised 7-10-92) Page i =� <br />