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SA N . tJ U A Q U I N Environmental Health Department <br /> -- C O U 1\1 T Y —• <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> .,,. , , ,.. . . �.. ;,, .:.. a k A a a iiifiiiiisiiii <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 /> dans 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 PILOT TRAVEL CENTER LLC ( FLYING J TRAVEL CENTERS #618 <br /> NAME: ) <br /> FACILITY <br /> ADDRESS: 1501 N . JACK TONE RD . RIPON CA 95366 <br /> TANK ID #39 - #7 TANK SIZE: 1 , OOOGAL PREVIOUS TANK <br /> CONTENTS:_ RUNOFF OIL <br /> irttMtfrtkie*#*#w*rlsrta#a +t*intr��.kNtktir*viii-katart#+�+,t M1irk+�-1rrRrMkMs iy** i <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 RANCHO <br /> City: CUCAMONGA Zip: 91730 <br /> Phone #: 8( 88 ? 872-7581 Date Tank Removed: 01 /02/2020 <br /> iiii*i**iFwtM*R <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor_A� > AM3 �� V:"t_ C� C, <br /> Address: A t3�,vp . City: tSSAJ PENA <br /> Phone #: 10 SZ3 L( zY3 C) <br /> Authorized representative of contractor certifying through signature below that the tank has been ea nteminated in an <br /> approved annex as 1equired by Cal EPA. <br /> Name: rt 1�! / Title: d �5 <br /> Signature: Date Q 'tJG <br /> ** i*i++ii" 'k+,iii*+++++iR+.++.fik+rr4## rrrlA-Irlx#ii,ttrt►i}i-k+,k+ii+.fi4*Irks+Fi##*}fs}ra#1.i+^a+rkN#hiYiii�i�+ii <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank andfor piping, <br /> Facility <br /> Name: ZUS LANA 6CL,4M11c ` rr'b tt ) <br /> Address: - City:AZ- U��( Zi <br /> p: `� <br /> Date Tank Received: / - •zpr�bCj <br /> Name: 4 A/ TNIe: : to. 400u Signature: Datej�-�j <br /> 9of10 <br />