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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD ••tt•••••••••••rr•rrr»••t•t♦•tt•••rrr•tu•t•••trt•••rr•rrtrrt•••rtrr•tutr»ttsut•u••ruttr•trtrrt trtrr• SECTION I - Public Health Services Tracking Sheet will accompany each tank affixed with Its site identification number. The Tracking Sheet Is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: N(C)ACK D LA -AP FACILITY ADDRESS: N7 S 10 O/ 02 D3a� I NPEE- U S TANK ID #39 - �7/ � k Description: QMC - U . 5. ••.••••••rr••t•••r•try••rrtt•rtttr•rtrttt•r•••»••ttu•tt••urrtttu•t•t•tt••u••tt•rtrt•trtt••ttttt••u ttr SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Ind e Sie�: PN MET C,IZ :!3E7Z11 / CE , lNC . Address: 2-7 3 5 TFEPEL bR. STE. #E City: STOCK TON zip: _95Z(15 Phone #:(209_)__9'48 `(c�/ Date Tank Removed: •••ttr..rr•••••••••••..•••trttttt•r•t•r•u•ttr tort+tt••••••»r•t•••tt•t•tt••... ••••••t••t••••t ••tu••tt••t SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: V\fESTI2N IVITt Address: 2--7 35 IEE -PEE hit. STt:. e City: S7 -()C -_ C)N Zip: Q 5 205 - Phone #: c 2L2) 948-(p/2-4 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. SNA Title:_ FIEF Su P -r. � L'KI51' ........•..........r•r••trtrt••••••tttr•as•»t»t••u ttttr»••ttttrut•••••turrru•r• SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: CAL - COA57 M FC—i CO Address: 242- '-1 AC,n(AP, tZOA�, City: Tukco[_!< zip: G53S0 Phone #: Date Tank Title: •r•t••t•A•••tr••ttttrt•••ttt•••tttr••••ttttt••ttttttr•tttttt•••1•ttttt•t••••••ttttt•••tttttt •••r•tttrtt• EN 23 049 (Ravtaed 7-10-92) Page 10