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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION I - Public Health Services Tracking Sheet will accompany each tank affixed with its site identif-iSation number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 duvs of acceptance of the Lank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. <br />FACfI-TI'YNAMF. Airport Passenger Inc. <br />FACUM ADDRESS: 2305 S. Airport Way, Stockton, CA <br />TANK iD #39 - �y7n ^ D / Tank Description:/.nnn 8�1 i .t; Ami <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. Paydirt Excavating Co. Inc <br />Address 269 Oregon ST City; Ripon tip: 95366 <br />Phone y: ( )209 599-2347 Date Tank Removed: <br />........................................................................................................... <br />SECTION 3 - To be tilled out by contractor 'decontaminating tank•: <br />Tank Decontamination Contractor. Paydirt Excavating Co. Inc. <br />Address; 269 Oregon St City; Ripon ZIP: 95366 <br />Phone #:( 20Y 599-2347 <br />Authorized representative of contractor certifying through signature below that the Lank has been decontaminated in an <br />approved manner as required by Cal EPA. <br />Signature: Title: <br />SECTION 4 - To be signed and dated by an authorized rvpmsentative of the treatment, storage, or disposal facility <br />accepting tank and/or piping. <br />Facility Name: Cal -Coast Mfg. <br />Address: 1540 Lynwood City. Turlcok Zip: <br />Phone #:( ) <br />209 668-9382 <br />Date Tank Received: <br />Signature: Title: <br />EN 23 049 (RevtaW 1-10-92) Page 10 <br />95381 <br />