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10/17/2000 09:00 2094683x43 FIFTH FLOOR PAGE 10 <br /> SAN JOAQUTAT COUNTY PUBLIC MrALTH SERVICES <br /> ENVMONN ENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANTE DISPOSI'T'ION TRACKING RECORD <br /> SECTION 1-Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit bolder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY *LAME: P A C I I C AVENUE ARCO <br /> FACILITY ADDRESS: 6425 PACIFIC AVENUE <br /> TANK ID #39- TANK SIZE: 10, 0 0 0 PREVIOUS TANK CONTENTS: GASOLINE <br /> MwW4WMRMF#MMMMRFwWMRM�MRMRiMWMM#iii#i###i#W##RR}##}rt##MWRFWWMRR##W#W#iWR##iR##M+YMMMRMWRMFkMWMWWRMWFWMWMMMM# <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Cmuaetorr W. A. CRAIG. INC. <br /> Address: 6940 TREMONT ROAD City: DTXON zip: 95620-9603 <br /> Phone#: ( 7 0 7 ) 693-292q Date Tank Removed: <br /> xii#i###W######WF#MWwFk#R#M##MRxi##k##i#WWWMWMMMMMRMi+k#ki#i#}k#i#WM'iF#RR#####+M##k#.MMMMWMwwwwwWR4iii4at#Mini <br /> SECTION 3. To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: W. A. C R A I G, I N C . <br /> Address: 6940 TREMONT ROAD City: DIXON Zip: 95620-9603 <br /> Phone#: ( 7n7 ) 693-2929 <br /> Authorized representative of contractor certifying througb signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: LELAND YIALELIS Title: GEN . MANAGER IeOCTOBER 18, 2000 <br /> M#WiWWMWkRM WFMR#iii#ih##ii#i#i}###M#WFi##iiihi##WiMwWwMMR#M#ih###}wrtrt}MRii#ii#i###W#W WWW*WMMWRR#Mil <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank andlor piping. <br /> Facility Name: <br /> Address: City: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> Wii###i#ii#i#4RwW#wwW}WkRWW4MRWFi#MMMi3M##MM#MiRRR###ii#x###MMR####MM#MW WMMMMkMM4M#i#####<}###W}##i##WRiw <br /> EH 23 046 (Revised 08113199) Page 10 <br />