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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />EWIRONMENTAL 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 resumed. <br />FACILITY NAME: CHEVRON SERVICE STATION <br />FACILITY ADDRESS: 301 W. KETTLEMAN LANE, LODI <br />TANK M#39 - 2174 TANK SIZE: 10,000 PREVIOUS TANK CONTENTS: PREMIUM G A S <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: M U S C 0 EXCAVATORS, INC. <br />Address: 255 PARR BLVD City: SACRAMENTO Zip: 94801 <br />Phone ,#: ( 707 579-0250 <br />Date Tank Removed: <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: <br />Address <br />255 PARR BLVD. <br />Phone #: ( 510 ) 970-7462 <br />ECI ERICKSON <br />City: RICHMOND Zip <br />94801 <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. M U S C O Title: <br />PRESIDENT <br />Signature: <br />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: ECI E R I C K S O N <br />Address: 255 PARR BLVD <br />Phone #: 5( 10 ) 970-7462 <br />Date Tank Received: <br />City: RICHMOND <br />Zip: 94801 <br />Name: Title: Signature: Date <br />EH 23 046 (Revised 9/11/96) Page 10 <br />