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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*********************************************************************************************************** <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br />with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br />Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAIME: CHEVRON SERVICE STATION <br />FACILITY ADDRESS: <br />TANK ID #39 - 2170 <br />301 W. KETTLEMAN LANE, LODI <br />TANK SIZE: 10,000 PREVIOUS TANK CONTENTS: MID GRADE GAS <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: M U S C O EXCAVATORS, INC. <br />Address <br />2155 NYLA PLACE <br />City: SANTA ROSA Zip: 95401 <br />Phone #: ( 707 ) 579-0250 Date Tank Removed: <br />*********************************************************************************************************** <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: E C I E R I C K S O N <br />Address: 255 PARR BLVD City: RICHMOND Zip: 94801 <br />Phone #: ( 51 0) 970-7462 <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. <br />Name: BRYAN H. MU S C 0 Title: PRESIDENT Signature: Date <br />*********************************************************************************************************** <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 Name: ECI E R I C K S O N <br />Address: 2 5 5 PARR BLVD <br />Phone #: ( 510 ) 970-7462 <br />Date Tank Received: <br />City: RICHMOND <br />Zip: 94801 <br />Name: Title: Signature: Date <br />********************************************************************************************************* <br />EH 23 046 (Revised 9/11/96) Page 10 <br />