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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> wwwwwwwwwwwwwwwwww*wwwwwwwwwww*w*wwwwwwwwwwwwwww*w*wwwwww+�r�r*w�rwwa�w*w*+►****s**rww�*#,r**s*rwsw�**sww*��ww*w* <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Street shall accompany each tank affixed <br /> with its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health <br /> Division within 30 day of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME.Waterloo Liquor <br /> FACILITY ADDRESS: 2512 E. Waterloo Road Stockton Ca 95205 <br /> TANK ID #39 - 24 Iib _ L. TANK SIZE- 12,000 PREVIOUS TANK CONTENTS: unledad gasoline <br /> 4 w w w w w w w w**r��k ww w w»w***w*+Mwwww+Mwwiww�YwwM�www+Ywwwwwwwwww ww www�M*yi wwwwwwwiMw*+hwwwwww�Fw�k�wwww�Fww ww*wM�*�wwww�wwwwww <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: James J. Hoblitzell <br /> Address: <br /> Box 30331 City: Stockton CZip: <br /> a 95213 <br /> Phone <br /> 209' 943 7793 Data Tank Removed: 10 June, 1998 <br /> #: (�, <br /> «x�wwwwww**wwwww*****wwwwwwwwwwwwwwwwww**w**+�w*�rw�rwwwwwwwwwwwww*wwwrwr�*w+w**w*swwr�wwwwwwwswwwww*ww*www*wwww# <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> sames as tank, removal contractor <br /> Tank Decontaminad Contractor. <br /> Address: City: Zip: <br /> Phone #: (�� <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> spanner . consistent with trade practices. rr <br /> Name: Title: C4W- c Signature: ate �4Jt7lt.G <br /> w+rwwwwwwww�r**s***w+«www*wwww+wwww+�w*�aww+wwww*www�rw+wr�w*r�wr�wrwwsww+**rwrr�w+rw�sswww w*+s+rr*+w*ww*sw+�w+www <br /> SECTION 4 » To be signed and dated by an authorized representative of the tir=ent,storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Cal Coast Tank <br /> Address: W A-(,NJ �� 't=� City: Turlock, Ca Zip. "r S <br /> Phone #: 2 �%�W � ✓� i, <br /> 10 June, 1998 <br /> Dau T Rerxived: / n <br /> Name: 7/f• tle: �/ `- Si Date r V YL <br /> �*�***www*r.**+•w+***wwrwr*+•rww•ww*rwwwwwww*www***�*w•wwww***,�*w***� **wwwwww*wwwwwwwwww»awswww*wwwwwww <br /> EH 23 046 (Revised 9111/96) Page 10 <br />