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F641N%VIRONMENTAt, HEAUrn MPREQW ED SAINT JOAQUAL COUNTY SEP 2 8 2016 'feleptionea (2.09) 4683 3426 Fac : (209) 468-34331 UNDERGROUND STORAGE TANK DISPOSITION SITION TRACK19M RE r. NTAL HEALTH v * z**ibh-. isrh .•.* vkA*k* :• .-, s*k % . .*hh&#t-k : d> *C:i*kib:4k .hi:tARfi 'kh:':d .R .-.hx*t*bxkA**k .* h3ifiikfrhfr . R * i.- if.R* ..A•�FT, r , EN 1 SECTION 1 — SJC Envirunmental Health Department's Tank Tracking Sheet shall accompany each tank affixed with its site identification numbar. The Tank 'racking Sheat is to be returned to the Environmental Health Department within 30 da s of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that this form is completed, and returned . FACILITY NAME : Spaulding Trust Property FACILITY ADDRESS : 540 North EI Dorado Street, Stockton , CA 95203 TANK ID #39 - TANK SIZE : PREVIOUS TANK CONTENTS : fuel . .::�:Fk&: e:$Se:+::k4c9c*:k:rie k:t:'tJ:x*;s'i::iC:+::: iC�':Y:SY:K�. 7'C:C:��:�C}:� .F*"i•:rjf X�fIF:FJ:*IC�P�G1Y:4:�'r�C)F}:n^�:�'J:*'fC:��C'*'Y:�*:{'�. yt:i�.'1�iE:':ier. :i*4esk:%�*>:•i:is kn•k�ckx9c� SECTION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Advanced GeoEnVironmentc:l , Inc. Address: 837 Shaw Road City: Stockton Zip: 95215 Phone :1: ( 209 ) 467-1006 Date Tank Removed: **h'**. $:4 SECTION 3 - To be filled out by contractor "decontaminating tank" : Tank Decontamination Contractor: Advanced GeoEnvironmental , Inc. Address: 837 Shaw Road Stockton 95215 City: Zip : Phone #: ( 209 ) 467-10GS Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA , Name: Title : Signature: Date 'J::K'�k*jt'A•:F*�C�C3t7�f::':* A :%:'%t1k•t'&9r)}':+;�C*jC* �*�:�T:�. *�CY'�. J+G�:>:�ClC*�C�G�:::•'*�( :F�:.F:�:K;%:YA�'�C:y�**�'>N:�*�C�1C�C:kY1F:F':Y�C**d:'9e:t:4'9'>'.'"�'*�C I. '*]. 'If�I'�GlC X:��G'�:�C'�C�. ICY . SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility accepting tank and/or piping . Facility Name: West Coast Equipment Address : P. O. Box 2368 City: Turlock, CA Zip : 95381 Phone #: ( 800 441 -8544 Date Tank Received: Name: Title: Signature: Date M 23 046 ( Revised 7/26/2016 ) 9