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SANJ O A Q U I 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 : FAC #7049 ARCO am/pm Fuel Facility <br /> FACILITY 800 E Kettleman Lane, Lodi , CA 95240 <br /> ADDRESS : <br /> TANK ID #39 - 10339507.003 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 85742 <br /> Address : 3206 Luyung Drive City : Cordova Zip : <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 p <br /> Name : Republic Services Forward , Inc . <br /> Address : 999 S . Austin Road City: Manteca Zip : 95336 <br /> Phone #: <br /> 209 ) 982=4298 <br /> Date Tank Received : <br /> Name : Title : Signature : Date <br /> 9of10 <br />