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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SI11, INLIMER 10 <br /> SECTION 1 - 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-IOCKION <br /> FACILITY ADDRESS: 2201 WEST WASHINGTON STRELT, STOCKTON, CA 95203 <br /> TANK ID 1#39 - JV —TANK SIZE: 250-1000 G PREVIOUS TANK CONTENTS: GASOLINE <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 /> Tarty 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: 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 9/11/96) Page 10 k. <br />