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ENVIRONMENTAL HEALTH DEPARR EE) SAN JOAQUIN COUNTY Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 15 2015 UNDERGROUND STORAGE TANK DISPOSITION TRACKING �QI MENTAL PAIaTAIIcNT SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: City of Stockton- 800 East Main FACILITY ADDRESS: 800 East Main Street, Stockton, CA 95202 TANK ID#39- TANK SIZE: PREVIOUS TANK CONTENTS: ******************************************************************************************************** SECTION 2-To be filled out by tank removal contractor: Tank Removal Contractor: Advanced GeoEnvironmental, Inc. Address: 837 Shaw Road City: Stockton Zip: 95215 Phone#: 2( 09 ) 467-1006 Date Tank Removed: ******************************************************************************************************** SECTION 3-To be filled out by contractor"decontaminating tank": Tank Decontamination Contractor: Advanced GeoEnvironmental, Inc. Address: City: Zip: Phone#: Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date ******************************************************************************************************** SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: West Coast Equipment Address: City: Zip: Phone#: U Date Tank Received: Name: Title: Signature: Date EH 23 046 (Revised 07/17/14) 9