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SANSIJ U AQ U I N Environmental Health Department <br /> C0UNTY - <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SJC Environmental Health Department's Tank Tracking Shoat shall accompany each tank affixed with its <br /> site idontification number, The Tank Tracking Shoot is to be returned to the Environmental Health Department within 3Q <br /> gM of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this <br /> form is completed and returned. <br /> FACILITY m Fuel Facility <br /> NAME: FAC #7049 ARCO amtp y <br /> i <br /> FACILITY <br /> ADDRESS : 000E Kettleman Lane, Lodl, CA 95240 <br /> TANK 10 439 . 10339507.002 TANK SIZE : 10,000 gallons PREVIOUS TANK <br /> CONTENTS4 Ract ,lar Unleaded Gasoline <br /> k ♦ llaaaa ! • a . • a • aaa • ! • a . • elaaa •laala ! • • t1a! ! llr . a ! ll. aala • alrslala . l /tact 4a allaaaataalYYaY •a as• oasaa • slsar <br /> i SECTION 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor. Town & Country Contractors, lnc. <br /> Rancho <br /> i Address; 3206 Luyung Drive C(tY: Cordova Zip: 95742 <br /> Phone #: t 91G 6� 36.9500 Date Tank Removed . <br /> �;, • • . • . • . . • . • • • . • • • • . •• a • • . e • • • • uluraa • • a • • • • • • ! laauluu • • car • rr , auu • auauaalulaaaalaa •» laiaaa • a� <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Belshlre Environmental S©rvieest, Inc. <br /> Address: 25971 Towno Center Drive City, Foothill Ranch Zip; 92610 <br /> Phone #: f 949 1 460.5200 <br /> Authorized representative of contractor certifying through signaturo below that the tank has been decontaminated In an <br /> approved manner as required by Cal EPA. <br /> Paul FreemanTechnician <br /> Name. Title: Signature: Date Ito lig <br /> •aaaarr+aal�aaararaaa aeawu+arnuauau uuauuraaa*! aiaburaaaaraaranasra ►thh►rar.asw eaararaarr <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank andfor piping. <br /> Facility � � � Recolo Ha Road Landfill <br /> Name: � 9y y <br /> Vacaville <br /> Address: *0240AMM&KlLamd 6426 Hay Road City, LlI 3i Zip: "M 95687 <br /> Phone #: <br /> { I 88848 707-67&4710 <br /> Data Tank Received: 7 <br /> Name : iert Alot �-,5� Ti11o: WCThr'tlPl4S(,qr Signature: Date <br /> 90110 <br />