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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 identification number. <br />The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or <br />recycling facility. The permit holder is responsible for ensuring that this form is completed and returned <br />FACHM NAME: Airport Passenger Inc. <br />FACHMADDRESS: 2305 S. Airport Way, Stockton, CA <br />TANK ID #39 - a7 AL - O Tank Description: 4,000 gallon diesel <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 ft: ()209 599-2347 Date Tank Removed: <br />................................................................................................••...•..•.• <br />SECPION 3 - To be filled out by contractor •decontaminating tank': <br />Tank Docontaminatiou Contractor. Paydirt Excavating Co. Inc. <br />Address: 269 Oregon St City: Ripon Zip: 95366 <br />Phone #:( 209 599-2347 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved maim" as required by Cal EPA <br />Signature: Title: <br />...••••...•••.........•.................................•..•...............................•...•..•.••..•.• <br />SEMON 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: Cal -Coast Mf <br />Address; 1540 Lynwood City. Turlcok Zip: <br />Phone tY: ( ) 209 668- <br />9382 <br />Date Tank <br />Signature: Title: <br />EN 23 049 (Reviad 7-10-92) Pago 10 <br />95381 <br />