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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />L—VVI tONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />*#####*##It###*###X11#***####It#*M###*####It**####***###############X11####*###*##*#####*##*######*##########*#### <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 recycking facility. The permit holder is responsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME; <br />FACILITY ADDRESS: <br />CHEVRON SERVICE STATION <br />301 W. KETTLENAN LANE, LODI <br />TANK ID 439 - 156642 TANK SIZE. 1, 0 0 0 PREVIOUS TAINK CONTENTS: WASTE O I L <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: m U S C 0 EXCAVATORS, INC. <br />Address: 2155 NYLA PLACE <br />Phone #: ( 707 ) 579-0250 Date Tank Removed: <br />City: SANTA ROSA <br />SECTION 3 - To be filled out by contractor "decontaminating tank": ' <br />Tank Decontamination Contractor: <br />Address: <br />255 PARR BLVD. <br />ECI ERICKSON <br />City: RICHMOND <br />Zip: 95401 <br />Zip: 94801 <br />Phone #: <br />510 ) 970-7462 <br />( <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. mUSCO <br />Title: PRESIDENT 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. City- RTr mnNin Zip: a/ anj <br />Phone #: 51 0 970-7462 <br />Date Tank Received: <br />Name: <br />Title: Signature: <br />EH 23 046 (Revised 9/11/96) Page 10 <br />Date <br />