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RECEIVED ENVIRONMENTAL HEALTH DEPARTMO 2 2016 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Telephone: (209) 468-3420 Fax: (209) 468-3433 DEPARTMENT UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION 1 – SJC Environmental Health Department's Tank Tracking Sheet shaft accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned FACILITY NAME FACILITY ADDRESS 8476 E. Kettleman Lane Lodm, CA 95240 TANK ID #39 TANK SIZE: 350_.Cjallon PREVIOUS TANK CONTENTS:Gasoline *************##*****#***##******wwwwwwwwww**w*w******#*#www***********www****w**wwwwwwwwwww*w******#**** SECTION 2 - To be filled out by tank removal contractor Tank Removal Contractor-Teuy-j) _Hamilton _ Address: 1502 Westbrook Court city Modesto zip: 95358 Phone #: ( 209 )_404-7700 Date Tank Removed: SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor:_ Tp= ❑_ Hamilton Address: Same as aboye „ _ City Phone #: Zip: Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Ter D. Hamilton Title: Contractor Signature: Date ***##**************************************************#*##*#*#*#*w**#wwwwwwwwwwwwwwwwwwww*************# SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping Facility Name: Modesto , Ii ink Cam.pany, Inn Address 1425 9th Street city. Modesto Phone #: ( .09 ) 522-1435 Date Tank Received: zip: 95354 Name: Title. Signature: Date EH 23 046 (Revised 7126/2016) 9