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n <br />L] <br />ENVIRONMENTAL EPA ENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br />and returned. <br />FACILITY NAME: California Highway Patrol #265 <br />FACILITY ADDRESS: 3330 North Ad Art Road, Stockton, CA 95215 <br />TANK ID #39 - TA0515660 TANK SIZE: 12000 gal. PREVIOUS TANK CONTENTS: Motor Vehicle Fuel <br />******************************************************************************************************** <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: B&T Service Station Contractors <br />Address: 630 South Frontage Road City: Nipomo Zip: 93444 <br />Phone #: ( 805 929-8944 Date Tank Removed: <br />******************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Adams Services <br />Address: 406 East Alondra Blvd City: Gardena Zip: 90248-2902 <br />Phone #: ( 310 523-4430 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. <br />Name: Title: Signature: Date <br />******************************************************************************************************** <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: Republic Services Vasco Road Landfill <br />Address: 4001 North Vasco Road <br />Phone #: ( 925 ) 447-0491 <br />Date Tank <br />Name: Title: <br />EH 23 046 (Revised 7/26/2016) <br />City: Livermore <br />Zip: 94551 <br />Signature: Date <br />RE( <br />ENVIRONMEN"I t-1 <br />N"I <br />9 <br />