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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone : (209) 468-3420 Fax: (209) 468-3433 <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> * Ktt}#*#t}#}*##ff#####*1kt**k###*#t#f#**k#t}##**#**}tkw}*kkA*kwtKkftkktltt#*}kk#k##}*f*kk**k}Mkw**ka}k** <br /> SECTION 1 — SJC Environmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental Health Department within 30 days of <br /> acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form Is completed <br /> and returned. <br /> Spaulding Trust Property <br /> FACILITY NAME: <br /> 540 North El Dorado Street, Stockton , CA 95203 <br /> FACILITY ADDRESS: <br /> TA 0520808 <br /> TANK ID #39 - TANK SIZE: 500 fuel <br /> PREVIOUS TANK CONTENTS: r <br /> SECTION 2 - To be filled out by tank removal contractor. <br /> Tank Removal Contractor: Advanced GeoEnvironmental, Inc. ' <br /> Address: 837 Shaw Road City. Stockton ZIP: 95295 <br /> Phone * 2( 09 ) 467-1006 Date Tank Removed: <br /> SECTION 3 - To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor: Advanced GeoEnvironmental, Inc. <br /> Address: 837 Shaw Road City: Stockton Zip: 95215 <br /> t <br /> Phone #: { 209 ) 467»1006 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA <br /> Name: Title: Signature: Date <br /> 1. <br /> r <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: <br /> West Coast Equipment <br /> � <br /> Address: P • 0 . Box 2368 City: Turlock, CA Zip: 95389 <br /> Phone #: 800 441 -8544 / <br /> Date Tank Received : `~l t <br /> Name: � Lle: ZGZ� """" Signature ate <br /> s <br /> f <br /> I <br /> I <br /> Ef123 046 (Revised 7126/2016) g i: . " i . ; ; <br /> s <br />