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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> «ww######w#+w*#####**+*###+*#*#+*w+#+***###***#**www*##*wwwwwwwwww*+++**####**w******#*+#**+****##******w** <br /> SECTION 1 - Public Health Services Environmental Health Division Tank Tracidng Sheet 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 days of acceptance of the tank by the disposal or recycling facility. The permit Folder 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 - —3. TANK SIZE: 12,000 PREVIOUS TANK CONTENTS: unledad gasoline <br /> «#*###*++wwww*wwwwww*##*####*###*########w#*w#*+#wwwww+www*wwww+www+wwwwww+wwww**w#wwww#wwww#wwwwww##+ww+*w <br /> SECTION 2 - To be filled out by rank removal contractor. <br /> Tank Removal Contractor: James J. Hoblitzell <br /> Box 30331 Stockton, Ca 95213 <br /> Address: City: Zip: <br /> Phone a: �� 943 7793 Date Tank Removed: LO .Tune, 1998 <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> sames as tank. removal contractor <br /> Tank Decontamination Contractor. <br /> Address: City: Zip: <br /> Phone f1: ( ) <br /> Authorized representative of contractor certifying through signature below that the tank has been decoataminated in an approved <br /> Baer , consistent with trade practices. <br /> Name: L1T}.��L _Title• 4"e Signature: <br /> +Y#�*w*####*+Y�kw#s*w*#�►#w#****i*#ww*****##*#***#iswr+h�Yw#w###******#«#*�w*+F#**##** +w*w***#�M*�F**#�M#*i**** <br /> SECTION 4 - To be signed and dated by an authorized representative of the treattrtent,storage, or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name: Cal Coast Tank,w,1 1 <br /> Address: DD p-Lu U _ City- Turlock, Ca Zip. <br /> Phone #. Z v fG 3 q 5 <br /> Date Tank R=ived: 10 //June, 1998 r Q <br /> Name: Clf( r r Title: t) 1 t:5 _ Signatunc: ate <br /> EH 23 046 (Revised 9/11196) Page 10 <br />