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SANJO A Q U ( N Environmental Health Department <br /> -- COUNTY — <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 <br /> site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 <br /> days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br /> form is completed and returned . <br /> FACILITY <br /> NAME : PILOT TRAVEL CENTER LLC ( FLYING J TRAVEL CENTERS #618) <br /> FACILITY 1501 N . JACK TONE RD., RIPON CA 95366 <br /> ADDRESS: <br /> TANK ID #39 - #7 TANK SIZE: 1j000GAL. PREVIOUS TANK <br /> CONTENTS: RUNOFF OI <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JONES COVEY GROUP INC <br /> Address : 9595 LUCAS RANCH RD. #100 City: RANCHO Zip:91730 <br /> Phone #: ( 888 ) 872-7581 Date Tank Removed : <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: CES - Controlled Environmental Services, Inc. <br /> Address: 50 Sand Creek Road, Suite 330 city: Brentwood zip : 94513 <br /> Phone #: 9( 25 ) 447-0491 <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 /> Name: Title: Signature : Date <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 <br /> Name: REPUBLIC SERVICES LANDFILL <br /> Address: 4001 N . VASCO ROAD City: LIVERMORE, CAzip: 94550 <br /> Phone M <br /> ( 925 ) 447-0491 <br /> Date Tank Received : <br /> Name: Title: Signature : Date <br /> 9of10 <br /> i <br /> I <br /> I <br /> i <br /> E <br />