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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ifff#YYii#i Yifli;fitiiiflYiif iifiifffiii iffif Yf if iiif ffiY Yiff;:ftf!!if#i!l Si iYfif YiliYi!l;iiiiiffffsf iif iff <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 E1Dorado Street, French Camp, California 95231 <br /> TANK ID #39 - 1S :J' CY Tank Description: 1" C_� L -c'c�r�s-i;� z1.5 <br /> titYii#Y#i#ii;#f ffif fiifi#ffiif ifffii iitY#i;Yf#if#t iYtf fffYiff#iiit##i#####ii#i#ilii#i#i;iYi##i#iifiifif ii# <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 /> i1#iY#f#ff ffif i##YY#f#fifiYY#####iif iiffif ff####iY#Yi#ffiffi#####if#;i##f#iff#f###if#####;#fffi##ffitititt <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 EP <br /> J � <br /> Signature: - -— Title: <br /> iYffi;#!iilii#!#iiiYY#s!Y#ii#ii#ifffiffif##iiiiiiii##fi###Yi###;;;iif###i#YYff#i##i;iif##i####iif#f Yif hitt <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 /> tii#fYfi##fiY;fi#i#iY###fff#i###i iiia Yiifi#Yii##Y##iif##Ytt##Yii#iii#YiY###YYf iii#fffi#if Y##Y##fi;iifttt <br /> EH 23 049 (Revised 7-10-92) Page �. <br />