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SAN JOAQUIN <br />--COUNTY <br />Environmental Health Department <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 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />NAME: <br />FACILITY 1601 EAST HAZELTON <br />ADDRESS: AVENUE, S I F\ I %iN CA 956201 <br />TANK ID #39 - TANK SIZE: PREVIOUS TANK <br />CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: RB ENVIRONMENTAL, INC. <br />Address: <br />4460 SOUTH HIGHWAY 99 FRONTAGE ROAD City: STOCKTON Zip95215 <br />Phone #:2( 09 932-0610 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: AMERICAN VALLEY WASTE OIL <br />Address: 16903 DARREN LANE, DELHI CA 095315 City: Zip: <br />Phone #: (209 ) <br />667-8857 <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 WEST COAST EQUIPMENT <br />Name: <br />1221 S. TEGNER ROAD, TURLOCK CA 095380 <br />Address: City: Zip: <br />Phone #: <br />668-9378 <br />Date Tank Received: <br />Titie: Signature: Date <br />9of10 <br />