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vow <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> aa#listrrraaaaaitsaatart#srrrar•Rs#aaasr#•autiaarir#•arsrrruarr#r#assaisaRt#t#tassasaarprsrassasasuars• <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank afrmed 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 /> FACILITY NAME: ESTATE OF HICKINBOTHAM, ET-AL. <br /> FACILITY ADDRESS: 816 E. HAZELTON AVE., =CKTON, CA 95203 <br /> TANK ID #39- Tank Description:1,000 GAL. GASOLINE TANK <br /> pili Nittgtrtititt aRtttiatrt#tit#ttiNtti Ht Utstf lttsrt•#t#a sr#ri!#lsails!laaf Hirsf tt#it#attttp♦tttttY <br /> SECTION 2 - To be filled oust by tank removal contractor. DAMES HOBLITZELL <br /> Tank Removal Contractor: <br /> Address: Box 30331 City. STOCKTON Zip. 95213-0331 <br /> Phone #: ( 209 ) 943 7793 Date Tank Removed: <br /> ••aiairtaisaawr#risssaaarriritaaisasairr••iislartarrri••isastsrrtrr#staarwrr••r#irrrrirrrrrrrr#iitiiifut <br /> SECTION 3 - To be filled out by contractor 'decontaminating tank": SAME AS SECTION 2 <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: ( <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA <br /> Signature: Title: <br /> •••rttivattrts atilt#iitrrauaassrraaRi•r#t♦asst»uaatsaatYt#+#rasaats ars»Rarrsatf aas#srii#i#i#pifa♦•i <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: CAL COAST TANK MFG. <br /> Address: 424 5. TEGNER b. City: TURLOCK Zip: 95381 <br /> Phone #: 2( 09 ) 668 9378 <br /> Date Tank Received: <br /> Signature: Title: <br /> ilia#1 HitpittttNlttNrrJRrrlRli#!#itif#afattittittiatitaaptatYRttiata Yttif tyrYRf iititrtf tttia Rafiti• <br /> EH 23 049 (Revised 7-10-92) Page 0 14- <br />