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12/18/98 FRI 09:33 FAX 5106096304 RHL DESIGN GROUP +.. RHL PETALUNA Zoll <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />+WiaaaaWWWixixWW####WW+W##aaWWWW###W####FiiiYY#Y#ii#i#iW#Wi##W#W##W##a######iii#W+YWWWWiiiiWiiWWWWWWWWWiiii <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification mtmber. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: A\1 RP°? -T Shell <br />FACILITY ADDRESS: <br />TANK ID #39 - L2Lq HOZ TANK SIZE: 1C, PDO PREVIOUS TANK CONTENTS: <br />xa�,rxxaxxaxxxxxYxxx*xaYaWxaaxxWxWxaxxxx#xxaaax+WaxxaxxxxxxaxaxxxxxxxxaxxxxxY#*a#xxsa##xxxxaaaxaaaxaxxxxxxxxx <br />SECTION 2 - To be filled out by tank removal contractor:: <br />Tank Removal Contractor: K - E Cur Arts C O n 5TR.uc i t o r-\ <br />Address: NOD OUB COr\ejo RO Ciry: NoAmey he ip: q 132'5 <br />Phone #: (916 ) -116- SSSS Date Tank <br />YaWxarax###a#WWW##WY#Yrt##a+#x##W*xaWx##x#Y+xx+###WxW#nix+#xa##Y###xxxx+WW#W#a#xWWW#Y##iWWWWx+Wi#a##xartWrt+i# <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Crospj, 4 Over*, <br />Address: edXoNek\a ST. City: OCL klt:.no Zip: %4`oZ� <br />Phone #: 033(.o <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: Title: Signaruxe: 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 <br />UV <br />Address: l630 W, 041, ST City: LoN6 Beast, Zip: C( 6t13 <br />Phone #: ( 5L21 qK.- S 443 <br />Date Tank <br />Name: Tide: Signature: <br />#WiaartxW#Yr#WWa#WY##Y##axY#+**a**#WxW*##*a*+x#xx###*##+a#s##YW*#s#*xa+#s#Yx#anva#Y#Y#aWarWY##siarasrtiriWY <br />EH 23 046 (Revised 10/19/98) Page 10 <br />