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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD SECTION I - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division 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: g64CON #4?-2- FACILITY FACILITY ADDRESS: j 470 At. MAIIV ST mA� T�cA TANK ID #39 - 1�D TANK SIZE: /0000 PREVIOUS TANK CONTENTS: GA5oL,.vE SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: JNS (On/STRuCr(,91y q Address: / Z00 E. :W VV City: C i-O V 1 5 Zip: / � l Phone #: ( 209 )299 /?4(o Date Tank Removed: 10-15-98 ***rtrt+****rtacart*aa*********rta**0000*artrtrtaaart+aart+,x**+rt*e**********rtrt«*«**rtrt«rt**rt***«r*****rt*******rt*******• SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: JI /5 Gon/STR ucrt01V Address: ?Zoo E. 5HAV✓ City: C 1_0 V/ 5 Zip93611 Phone #: ( 209 ) 299 1146 Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date 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: ECOLOGY e"0^17-XO L. /,VwSTklC5 Address: 255 f AR/L &I City: RIC HM oAID Zip. I.001 Phone #: ( 510) 235 1573 Date Tank Received: Name: Title: Signature: Date ****a*a**0000*rta**rtartrt*rtrta*******rtrt**0000000****************rt*artartaa*rt*********aa*******a*rta*aa******rtaa* EH 23 046 (Revised 9/11/96) Page 10