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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed <br />and returned. <br />FACILITY NAME: San .IOagUln COUnty HOUSehOId HaZardOUS Waste COnSOIIdatlOn FaClllty <br />FACILITY ADD <br />TANK ID # <br />26917 <br />7850 R A Bridgeford St, Stockton, CA 95206 <br />TANK SIZE: 5O0 gallon PREVIOUS TANK CONTENTS: USed Coolant <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Bagley Enterprises Inc. <br />Address:2370 Maggio Circle Ste 4 <br />209 � 367-4800 <br />city: Lodi <br />Date Tank Removed: October 5th, 2021 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Bagley Enterprises Inc. <br />2370 Maggio Circle Ste 4 <br />Phone #: (209 � 367-4800 <br />zip: 95240 <br />City: Lodi, CA zip; 95240 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br />manner as required by Cal EPA. � '1 <br />Name: Andy <br />Bagley Title:Opps Manager s;g <br />Oct. 5th, 2021 <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment,''stora�, or disposal facility accepting tank <br />and or piping. <br />Facility Name: San Joaquin County Household Hazardous Waste Consolidation Facility <br />Address: 7850 R A Bridge <br />ford St. City: Stockton, CA zip: <br />Phone if: ( 209 <br />Date Tank Received: <br />Name: 011ie Janvrin Title: Facility Manager Signature: Date Oct. 5th, 2021 <br />EH 23 046 (Revised 7/26/2016) 9 <br />