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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD t.f.•.ati.•.•.•.a..•tt.ait.•f•t«•..ff..af.....ai......•......aitta.••f aiiaaftta....atttltt t.... SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. The Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed and returned. FACILITY NAME: TOWN & COUNTRY HAY & FEED FACILITY ADDRESS: 4145 E. "AIN STREET, STOCKTON, CALIFORNIA 95215 TANK ID #39 - O 6 T Tank Description: ,�p a—Ge[c'1 ....t..•.1•t..•tt...aa...•.•11tH.a.........•.t..«.i.....t.a..ai...•..aa.atiaaiiiaa•t.a....a. SECTION 2 - To be filled out by tank �ERGYcontractor: Tank Removal Contractor: AA Address: BOX 1257 City: STOCKTON,CA Zip. 95201 Phone #: ( )Aq 4F3 71OR Date Tank Removed: .tf......t•f•f•f•.•........i.......f.................i•t•f.ft..................................itt....t.i.. SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: FAI (Y1N FNFRf;V Address: lox 125/ City: STOCKTON, CA Zip: 95201 Phone #: ( 20 4b3 7108 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA Signature: Title: SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping. Facility Name: THF I FARNFR fnMP Y Address: 2711 NAVY DRIVE City: STOCKTON, CA Zip. 95203 Phone #: ( ')n9 ) 1148 51498 Date Tank Received: Signature: Title: •tttttttf ttt•••tttt ttf••tit•f•iitttit.tttttat.ft.tttttitf tt.ft•tY••ttit Rtitt tifft}titait tt t.t tt tttttt♦ EH 23 049 (Revised 7-10-92) Pelle 10