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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> *tR#ss##iirtsss#ts*t##stttssRss#s*RtRSRs#s##s**tRetRsr##tss*#t•Rttst#st#rrRst##*tlsitsRs###*tt##iRtssls#*## <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed 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: <br /> FACILITY ADDRESS: 221-225 MINER AVENUE, STOCKTON, CALIFORNIA <br /> TANK ID #39 - Tank Description, 1,000 GALLON GASOLINE (ESTIMATED) <br /> #•t#*it!•rttt###t#t!####t*#t#tRRlt##sR#*#t RRR#•i#syt#t*##ttiRt##t#tttt##i RiRRt#♦**tRRRt#######*#t*#*ttRRt#* <br /> SECTION 2 - To be filled o by tan removal contractor: <br /> Tank Removal Contractor: rALCON LNERGY <br /> Address: P.O. $OX 125/ City: STOCKTON, CA Zip. Y5201 <br /> Phone #: 2( OO ) 403 7108 Date Tank Removed: <br /> R##t#r:tssrritstttsssssss#RRs##srr•Rt#ssst#R##*rtttRRRRSRtRtss##ssse**r*rst•Rs##*rrr#ttRSRRSRR#sssttr#sstts <br /> SECTION 3 - To be filled out by contrfor "d ntami ating tank": <br /> Tank Decontamination Contractor: �ALCONNERGI <br /> Address: 2.0. ly 122 City: STOCKTON, CA _ Zip: 93201 <br /> Phone #: ( 209 463 /108 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved mariner as required by Cal EPA. <br /> Signature: Title: <br /> s###*iii*#ifs#tsss#ssssts#*its##•r#R*RtR*#ssrs#tRs*****t##**tr#ssss*Rs#ss#Rs*t#tRRRs#*##s####s##*s#*t*rr#R# <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: THE LEARNER COMPANY <br /> Address: 1711 NAVY DRIVE City: STOCKTON, CA Zip: 95203 <br /> Phone #: ( (j ) 948 3498 <br /> Date Tank Received: <br /> Signature: Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />