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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <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: RMC Lonestar, Inc. <br /> FACILITY ADDRESS: 30350 South Tracy Blvd. , Tracy, CA <br /> TANK ID #39 - 1, 2' AndL Tank Description: Single wall steel <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Pacific Excavators <br /> Address: P.O. Box 968 City:Ajamo,CA Zip: 94507 <br /> Phone #: 5( 10 370-8783 Date Tank Removed: 1 - 2.S-q(, <br /> ------------ <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: <br /> Address: City: Zip: <br /> Phone #: <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 /> 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: H & H Shipping <br /> Address: 220 China Basin City: San Francisco, C2jp: 94107 <br /> Phone #: 41( 5 ) 543-4835 <br /> Date Tank Received: a2314(. <br /> Signature: SE€ CvPY oG r1A9jr-#Sr is 955404 Title: <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />