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6 <br />ENVIRONMENTAL HEALTH REPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSITION TItACIUNG RE, CO1W <br />SECTION 1 — S.1C Environmental Health Department's lank Tracking Street shall accompany each tank aflixrd with its site <br />identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Departinent within 30 days of <br />aCCOPU"nce Or Lhe tank by thL disposal or recycling facility. The permit holder is responsible for ensuring that this form is <br />completed and returned. <br />Haight Road Tank Removal Project, APN 061-150-38 <br />FACILITY NAME:„ <br />6426 E. Haight Road, Lodi, CA 95240 <br />FACILITY ADDRESS:—..-----� <br />500 allon Fuel <br />"l'AN'1� ld #39 - Pk �` '1'Al`J1C S1GL: � Pi3J3v1Cius'1'ANIt C()1`J`!IJ•I�l':lS: <br />*;*****;:*tai:*44;**I; k:k:K** :k:k04a ;#W;;N** 44;*4;41410 104*4 r�A,*:kW4; 4;k8;*4 osok*+k:k�F+k:k'd;:Fa4�8i4;*WrGWN+�k:M%sN:;N <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`: ( 709) 826-4252 Date Tank Removed: <br />City: <br />Los Bands Gip: 93635 <br />+NN<shit*Itk#W*+NN'Na+NNsW*Ht4k4"##+k##W##N++NWWN+:NWN��k:k k9;sFsK;1;A;�::k Y;*;KEN'k:l;'+kjk*;kik'K;N'A;WN<N�N;�kN<sG+NN"sGN�:kNI <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tani: Decontamination Contractor: D & S Dragline Service <br />Address: <br />Phone #: ( 209 <br />540 F Street <br />City: Los Banos Gip: <br />8264252 <br />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: <br />Title:: Signature: <br />Date <br />*;!**+**#I:#:k#is :04..#i: *W*#4:**#:k:k:r+:k#####*sl::i=:k#*W+NMN,+NNt410**1)*41 *;k41;1*lk***FMK4,*;kN•;ksGsN*:F-V***#*** <br />SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br />aCcuptir►g tank and/or piping. <br />)+acility Name: <br />Address: 1712 S Walnut Road <br />Phone ft: (,?Q_ 9 ) <br />M] ,st Coast Egttipnu-nt <br />��P� <br />City: <br />T urlocic 95380 <br />668-9378 <br />Date Tank Received: <br />Name: _Title: Signature:__ Date <br />skN: WWW##4144:4H**14Ns#Ntikjk.l;#;k;kk::k*#*:N:k:c:s***#lk****#:N+N##Hs*sNW#WWN<WN�N<N+#N�WsKN" <br />EII 23 046 (Revised 813/07) 10 <br />