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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD 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 - () �t5{ I C Tank Description: -�eCG GCei� tta..ata..at,a....a.alt.acre...,t...a...fi,.......fi.,,..atatt......aatttttat..a SECTION 2 - To be filled out�yLtan moval contractor: Tank Removal Contractor: AA Address: SOX 1257 City: STOCKTON,CA Zip: 95201 Phone #: ( )ng 46 7108 Date Tank Removed: ................................ti...................t.tttiiY...............................ttt.t.......... SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: FAI CON FNFRGY Address: Box 1257 City: STOCKfON, CA Zip. 95201 Phone #: ( 20 4b3 TIOR Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA- Signature: PASignature: Title: a............at;.........a..aaa..Yt.................atta.......a a.Yt.a..Y.Y.....;a....a....... 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 FORNFp r-nyIpaNY Address: 2711 NAVY DRIVE City: STOCUON, CA Zip: 95203 Phone #: ( )nq , 948 5498 Date Tank Received: Signature: Title: tttttttttt,tttttttttif tttittttttitltlttitlttttfiti tttt.,tttttit;t tYttti tt;i ttt ttttttt ttY tftt;ttttitttttf• EH 23 049 (Revised 7-10-92) Page 10