Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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 retumed. <br />FACILITY NAME: CHEVRON SERVICE STATION <br />FACILITY ADDRESS: 301 W. KETTLEMAN LANE, LODI <br />TANK ID #39 - 2171 TANK SIZE: 10,000 PREVIOUS TANKCONTENTS: REG G A S <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: <br />MUSCO EXCAVATORS, INC. <br />Address: 2155 NYLA PALCE City: SANTA ROSA Zip: 95401 <br />Phone #: ( 707 ) 579-0250 Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": ' <br />Tank Decontamination Contractor: <br />ECI ERICKSON <br />Address: 255 PARR BLVD. Cit,: RICHMOND Zip: 94801 <br />Phone #: ( 510 ) 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: <br />BRYAN H. MUSCO <br />Title: PRESIDENT 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 Name: <br />ECI ERICKSON <br />Address: 1. City: <br />255 PARR BLVD. RICHMOND <br />Phone #: (_=—) <br />0 ) 970-7462 <br />Date Tank Received: <br />Name: Title: Signature: <br />Zip: 94801 <br />Daze <br />