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SAN JOAO IN <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 />Jays 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 AVENUE, STOCKTON CA 956201 <br />ADDRESS: <br />TANK ID #39 - U x W, TANK SIZE:_ i i �� PREVIOUS TANK <br />SECTION 2 as To be filled out by tank removal contractor: <br />Tank Removal Contractor: RB ENVIRONMENTAL, INC. <br />Address: 4460 SOUTH HIGHWAY 99 FRONTAGE ROAD City: STOCKTON Zip; 95215 <br />Phone #: 209 <br />� 932-0610 Date Tank <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />AMERICAN VALLEY WASTE OIL <br />Address: 16903 DARREN LANE, DELHI CA 0 <br />95315 City: Zip: <br />Phone #: ( 209 667-8857 <br />Authorized representative of contractor cert <br />ifying through signature below that the to k has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Name: Title: Signature: ate 5� <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, sto age, is disposal facility <br />accepting tank and/or piping. <br />Facility <br />Name+ WEST COAST EQUIPMENT <br />1221 S. TEGNER ROAD, TURLOCK CA 095360 <br />Address: City: Zip: <br />Phone #: <br />2( 09 ) 668-9378 <br />Date Tank Received: <br />Name: C! I PCt-� 0 _ Titles ( C Signatur " r_Z '� <br />9of10 <br />Date <br />