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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSI<ON <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SITE LI'LXBER 9 <br /> SECTION l - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed <br /> with its•site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: FORT OF S-f`OCK'ION <br /> F'ACILITY ADDRESS: <br /> 2201 I-VEST WASHINGTON STREET, STOCKTON, CA 05203 <br /> DIESEL <br /> TANK ID .#39 - 1Z�-Qt_&TANK SIZE: 250-1000 G PREVIOUS TANK CONTENTS: <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: City. Zip. <br /> Phone #: ( ) Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <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 approved <br /> manner as required by Cal EPA. <br /> Name: <br /> 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: City: Zip: <br /> Phone #: ( ) <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 9111/96) Page 10 L <br />