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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> !it###t/f*ti#1Rf#t#tt/t ttttt it####«ttit#t*R#t#t!!•!ltiRt!♦ffr«tR#«t##tR#frttt#ti#«###**#*#/trtrrttttlt#f Rti <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 /> FACILI'T'Y NAME: <br /> FACILITY ADDRESS. 221-225 MINER AVENUE, STOCKTON, CALIFORNIA <br /> TANK ID #39 - Tank Description: 1,000 GALLON GASOLINE (ESTIMATED) <br /> *ls1R!•#rrftttt////#/Rtt#!t#Rttt#Rt*!*r Rrfr#«!#t«s:*!!!!*##RR*#R•ttit#tt«tttRrr##«l RtiRtRRr##tf•##tr•tltRR• <br /> SECTION Z - To be filled oV by tan removal contractor: <br /> Tank Removal Contractor: rALCONLNERGY <br /> Address: P,0, Box 1257 City: STOCKTON, CA Zip. y5201 <br /> Phone #: 2( 09 1 463 7108 Date Tank Removed: <br /> ass«««s!t*assts#ttrfstf/rs#r«sssr*#*•f•r«•sssltRlrrRrtlRR*tarrrsrstrs#r«ssi!•sr#s«ts!*lsrsr#t«ssssrssss!!t• <br /> SECTION 3 - To be filled out by contr to: "d ntami ating tank": <br /> Tank Decontamination Contractor: rALCONNERGI <br /> Address: City: STOCKMN, -CA- Zip: 95201 <br /> Phone #: 209 ) 463 /108 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Signature: Title: <br /> ;ECTION <br /> 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. 2711 NAVY DRIVE City. STOCKTON, CA Zip: 95203 <br /> Phone #: f 209 ) 18 3498 <br /> Date Tank Received: <br /> Siznature: Title: <br /> ##****tR#R«**ttt#/t###tt1lf RRt*R#R#tft#tit««i#1ttrRR#Rttii#tttt##R////ft««!t*Rtr#t/*RtR#Rf#*#tttt#ttt**# <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />