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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ##iR#i RRwRRiwiaxi■Assisax#iasis nisi#i#s#si ii##i#iii#i#iiiiii#s#i##siiiiississsasiasissaaasaasaataa**\iiia## <br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identifuation 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 /> FACIL= NAME:_ Waterloo Liquor <br /> FACILITY ADDRESS:_2512 E. Waterloo Road, Stockton, Ca95205 <br /> TANK ID #39 - �$- 1_.Ta4Y3 Tank Description: 12,000 gal. , -m=1*w6ed- gasoline <br /> 'gsoo�iisa»i##i###i#ittf###i#iiiif�#i#ia;#i <br /> SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. James J. xoblitzell <br /> Address: Box 30331 City Zip: <br /> Phone #: 2( 09_ 943 7793 Date Tank Removed: <br /> tsRRrwwMwiR•###RRRwixwwwwsisis##a##RSR#asxiswi#aii###RRRRRa twwaiRxs###si#Ri#■##as#isiiiiis#Risaiasasasiaas# <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 /> »###########wwwxi#siiiiR###iwisaaisiii#####iaiaasasi#####Ri##i#axaiiii+Riii###i***xisif*ix##ixxaifit*#ittiaR <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: Cal Cgast Mfg, <br /> Address: Box 1864, 424 S. Tegner City Turlock, Ca Zip- 95381 <br /> Phone #: 209 668 9378 <br /> Date Tank Received: <br /> Signature: Title: <br /> ##iii#ii+ifs#####My+�tasi####»s#ixtxxii##i tf+�#i#xaxx#iR#t#ii ii##i###Rs####iias##i#f a» /###*xa#1iis»##iixias• <br /> EH 23 049 (Revised 7-10-92) Page 10 <br />