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SAN JOAQUIN COUNTY PUBLIC HEALTH SER ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION 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 holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITYNAME: Safeway Inc. EPA # CAC 002571123 <br /> FACILITY ADDRESS: 6425 Pacific Ave Stockton CA 95202 <br /> TANK ID#39- TANK SIZE: 350 PREVIOUS TANK CONTENTS: Waste Oil <br /> SECTION 2-To be filled out by tank removal contractor: 9 <br /> Tank Removal Contractor: Jim Thorpe Oil , Inc. <br /> Address: P.O. Box 357 Cit,: Lodi, CA Zip: 95241-0357 at <br /> i <br /> Phone#: (209 ) 368-6175 Date Tank Removed: <br /> SECTION 3-To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Jim Thorpe Oil , Inc. <br /> Address:P.O. Box 357 City: Lodi , CA Zip: (5241-0357 <br /> Phone#: ( 209 ) 368-6175 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. Tank has been triple rinsed and is free from all sludge. <br /> l <br /> Name: Title: Signature: Date <br /> f <br /> i <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 /> Schnitzer Steel Products <br /> Facility Name: <br /> 120 0 Folsom Blvd. , Rancho Cordova, CA 95742 <br /> Address: City: Zip: <br /> Phone#: 91( 6 ) 985-4810 <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />