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n SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 /> FACILITY NAME: pacific Bell <br /> FACILITY ADDRESS: 10 East 12th Street, Tracy, Cailifornia <br /> TANK ID#39- 1 1 0 3 TANK SIZE:2, 0 0 0 Gal l diREVIOUS TANK CONTENTS: Diesel <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tank Removal Contractor: To be determined — see attached list <br /> Address: City: Zip: <br /> Phone#: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: F.G j <br /> Address: 25parr Boulevard City: RiGH d Zip-a"0.0 1 <br /> Phone#: (51 0 ) 235-1393 <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. <br /> Name: Title: Signature: Date <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: ECT <br /> Address: 2,55 Darr Bo 1 -W»rA City:RtchII1v.nd Zip: 94201 <br /> Phone#: ( I O <br /> Date Tank Received: <br /> Name: Title: Signature: Date <br /> EH 23 046 (Revised 08/13/99) Page 10 <br />