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SAN J o �jFiQ U I N Environmental Heatth Department <br /> r , 1 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> SECTION 1 — SJC Envionmantal Health Department's Tank Tracking Sheet shad accompany each tank affixed with its <br /> site identification number. The Tank Tracking Shoot Is to be returned to the Environmental Hoalih Department within 30 <br /> AaX§ of acceptance of tho tank by the disposal or recycling facility. Trio permit holder Is responsible for ensur€rig that this <br /> i form Is completed nM relumed , <br /> 1 <br /> FACILITY <br /> l NAME : FAC #7049 ARCO amlpm Fuel Facility <br /> FACILITY <br /> ADDRESS : 600 E Kettieman Lane, Lodi , CA 95240 <br /> � <br /> TANK ID X39 - 10339507.004 TANK SIZE 10,000 3110115 PREVIOUS TANK <br /> - - <br /> CONTENTS : ium UnIaadedd Gasoline <br /> sea . .. . . . . too " . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . f . . f. 11 . tf . .. . . . <br /> SECTION 2 - To be fed out by tank removal contractor. <br /> Tank Removal Contratiot ; Torun Country Contractors, Inc. <br /> s Ren ho 95742 <br /> Address: 3206 Luyung Drive City: COMM Zip: <br /> Phone ft: ( 916 _1 63S 9500 Date Tank Rorvttd: Wag( (o / 9 <br /> i <br /> ' • . . .. . NNlJ0 . , 0406-1 . t1. . . . too too , . a. too. . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . , . .. 1 . . . *to . . . . . . . . . 11 . . . . .. . . . <br /> SECTION 3 - To be filed out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor Belshire Environmental Services, Inc. <br /> Address: 25971 Towne Center Drive City. Foothill Ranch Zip: 92610 i <br /> Phone #: t 949 1 460.5200 <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 /> t4ame : Paul Freeman Title : Technician Signature : Date P7 1(p eel <br /> • 1 . ft , . 1 . ,. s ,r. . , . F . . . ,a. . 1 . f . . . t . 1 . . . t . 1 .. 1 . . . . . . . 1 .. { . 11i {. . 1 . . . . . 11 . . .. . .11 . .. 1. . , . fO . 1 , . i. . . . 11 .i . .1 • <br /> SECTION 4 - To be ssgnod and dated by an authorized representative of the treatment, storage , or disposal facility <br /> accepting tank and/or piping . <br /> racility <br /> Name : tsttF71QDtt )@CS�JttiDCr$(tl4G Recology Hay Road Landfill <br /> Vacaville <br /> Address: WWWKDWKRM6426 Hay Road _ _City: KAOMK Zip: 9W695687 <br /> Phoney Ar : <br /> f M t WhIAM 707-6784710 <br /> Data Tank Received : 7 <br /> ffjj�� c-, <br /> Nema : K r ei Tifle : 4/ �+ ( t l44` "r Signature : l -r—" " Date <br /> 9rt ie <br />