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- 316 457 1817 P.05 <br /> UHT)F HC,ROUtvt>S•t'ORAGE TANX DI'MO)SITION TRACKING RECORD <br /> •�{'{{f{atrsff!lfffaaslrsf4f ffaffRYYltsffsatNrs•'..r*♦*rAaNtaraaltaslYi serer♦*!lt�lfa�ffsYfaatf Nffafsastlf <br /> SI:C' ION t • Public HCAI(11 Servlcec Ttaeking Sheet will Re0mpaenp eachtank Affixed with iter site Identification number: <br /> The Trttting Stkect is to be returned to Public: Health Services within n .o dffs ot mccePt4ince or the lank by tha dispasat <br /> recycling facility. 116 permit holder is respf)risihle for ensuring Mat this formthis form is Completed and returned. or <br /> l'AC1Lr1-Y NAME: Fire-'Station No. 1Z <br /> F-ACTI-tTYAWMP-SS:_ 4010 E. Main Street - Stockton, CA 95202 - <br /> tANK It) #39 <br /> Tank Dencriptlan: l-S00 Callon Diesel. - 1-500 Gallon <br /> ••1{{4..af�;I�fafrf Yafaa•taf*fl�fasra!lrfRrsfail!•♦!•fs��•lYsrflflaff�aw+f�frf Yaraarff.allraaral.a�{a.{r�•�{ <br /> 41:L'17pN Z <br /> -To bo filled out by tank rertnvni cunitletnr: <br /> 'yank Remowd Contractor. Goins Environmental (hnstruction <br /> Aclr[ttsc: 4111 82nd Street <br /> City: Sacramento lip: 9 S 4 2(j <br /> Phone #: (-916) d S 4-5 9 4 5 Date Thnk Removed; <br /> ••�•.as�at.{a�iasffass♦ssaaNilMsaraatff.�Ataasss:aar=aaa{fwa.Rrwrrtsrratrtasftaawrsaawa.. _ <br /> To be filled nut by cnneractnr{dM- Miaminating lank- <br /> 'Rink Decontarninalion ContraMor; Goins Enviyonmentni onstructi n <br /> Mdr m: 4111 82nd Street ._ ._.`Ctty:--.9,uZi S F <br /> Phone <br /> Awlinclyod tepreseniative of contractor eerii[ying through sfgttatum below that the tank has been decontaminated in . . <br /> appmved maciget 89 uited by Cal <br /> Slgnvtnrc: � �' <br /> ♦t•of tiastaY fa�!!fY!lss.►f*f!!!!lsfsla♦r offs Mis♦sr*sssaft►.�ssflair►asst!!!►4f�es�rraiNlrwassNassa�{{H♦{ <br /> 4l�:GTfON d .To be signed and dated by ark avithorized representative of the treatttlent,storage,or disposal facility <br /> accepting lank and/or piping. <br /> FacitllyName:_ Cal Coastl%32=r <br /> Addrtm- 44V <br /> City: Z�.t r 1 a t k Zip;`9 S 3 81 <br /> Phone #rt (_209 l 668-9378 <br /> Dale Tank Received• <br /> siFnatut'C: Titles r <br /> ••...,t.f Rla�alr�a�r!{f�r��Y���lt�art�fa{ff141�ft{faattYfl�lfaa�#M�lat�t��tiiflt�r�r\��1rla{yAtNtlaaaNa <br /> t" 21 049 caowited 1-10-923 peg* tv <br />