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Environmental Health t3opart "# ent <br /> SAN JOANN <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SJC Environmenial i•tvalth Deparimetni's Tank Tracking Sheet shall accompany each tank affixed with its <br /> site identification numt�er . The To Trackmg Sheet is to be returned to the Environmental Health Dapartmont ta�Q <br /> � of Icceptanr� of the tank by the disposal or recycling facility. The permit holder is respons blo for rsn:,urinq that this <br /> I <br /> form is completed and returned. <br /> FACILITY FAC 97049 ARCO am)pm Fuel Facility <br /> NAME. <br /> FACILITY 800 E Kettleman Lane , Lodi , CA 95240 <br /> ADDRESS . <br /> TANK ID #39 - 0339507.003 TANK SIZE : 10,000 gallons PREVIOUS TANK <br /> CONTENTS : Rnf. r tlniesded Gay ine <br /> too <br /> SECTION 2 - To tbu flticarf cnii by tank removal contractor: <br /> Tank Removal Contractor: Town & Country Contractors, Inc. <br /> Rancho 85742 <br /> Address . 3206 Luyung Drive _ City: Cordova Zip: <br /> Phoncz 9: ( 9t6 ) 636a9500 Date Tank Removed :. �I (i <br /> p • r. a . •. . a . . a . . a . . . • • . . . . . . . at * . . . . . . . . . . . a . . . • . . . . . . . . . . . • . . aa . • a . a . . . a . • . a . . . . . • . a . . . . . . , . . , • . . . . , . . . . . <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Toru Dcentaminautn Contracrar_ Belshire Environmental Services, Inc. <br /> Address : 25971 Towne Center Drive City : Foothill Ranch Zip; 92610 <br /> Phone 0: 1 949 ) 460. 5200 <br /> Authorized representative of contractor caddying through signaturo below that the lank haS been decontaminated in an <br /> approved manner as required by Cal EPA. <br /> Ntrrno Paul Freeman Title : Technician Signature : _ pate <br /> ads . . u . . . . . . . .. a . . . . so * an . . . . . . . . • . . . a . a . . . . • a . u • . , a . . . a . aa, ,. ..,a •. ., . . , a ar•.. • . .r . . ,. a • w,. . . . r. . . .. <br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage , or disposal facility <br /> accepting lank andlor piping. <br /> Facility pGd lA?E t(r'426X b1bX ft rlE. Recology Hay Road Landfill <br /> Name : acavi e <br /> Address : 1A ( i 6426 Ha v Road _City Zip: 96M 95687 <br /> Phone 9 : <br /> ( 7p 707-6784710 <br /> Dato Tank Received : <br /> i <br /> Mame � ,Lcr � Tdltr: Cut 4g) �s4 � Signature : t Date ? � <br /> i <br /> 90110 <br /> I <br /> i <br /> i ! <br />