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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (204) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br />acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. <br />FACILITY NAME: Haight Road Tank Removal Project, APN 061-150-38 <br />FACILITY ADDRESS: 6426 E. Haight Road, Lodi, CA 95240 <br />TANK ID #39 - TANK SIZE: 500 gallon PREVIOUS TANK CONTENTS: <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: D & S Dragline Service <br />Address: <br />540 F Street <br />Phone #: ( 209 ) 826-4252 Date Tank Removed: <br />Fuel <br />City: Los Banos Zip: 43635 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: D & S Dragline Service <br />Address: <br />Phone #: ( 209 <br />540 F Street <br />City:_ <br />826-4252 <br />Los Banos <br />Zip: 93635 <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: Signature: 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: <br />Address: <br />Phone #:( 209 )_ <br />Date Tank Received: <br />1712 S Walnut Road <br />West Coast Equipment <br />City:_ <br />668-9378 <br />Turlock <br />Zip: 95380 <br />Name: Title:_ Signature: Date <br />EH 23 046 (Revised 8/3107) 10 <br />