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SANJ O A Q U I N Environmental Health Department <br /> - - <br /> - COUNTY - -- <br /> UNDERGROUND <br /> COUNTY - --UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SJC Environmental Health Departments 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 FAC #7049 ARCO am/pm Fuel Facility <br /> NAME . <br /> FACILITY 800 E Kettleman Lane, Lodi , CA 95240 <br /> ADDRESS : <br /> TANK ID #39 - 10339507401 TANK SIZE : 10 , 000 gallons PREVIOUS TANK <br /> CONTENTS : Regular Unleaded Gasoline <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Town & Country Contractors , Inc . <br /> Rancho <br /> Address : 3206 Luyung Drive City: CordovaZ; p ; 95742 <br /> Phone #: ( 916 ) 636.9500 Date Tank Removed : <br /> SECTION 3 - To be filled out by contractor "decontaminating tank" : <br /> Tank Decontamination Contractor: Belshire Environmental Services , Inc. <br /> Address : 25971 Towne Center Drive City: Foothill Ranch Zip : 92610 <br /> Phone #: ( 949 ) 460.5200 <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 Forward , Inc . <br /> Address : 999 S . Austin Road City: Manteca Zip : 95336 <br /> Phone #: <br /> ( 209 ) 9824298 <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> 9of10 <br />