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SAN .7C U%QLII N LOC".,A.i[. "F AN"VjrH -100I 87WRI CT <br /> (RIDWGROUND TANK DISPOSITION TRACKING RECORD <br /> JR4'sR!lRltR*ttYttff*!Rf**!*fflfltRR*RL Af***;*Rff#f}}fRttff**RR!*fRfRRRffttRR*f/RRftRRfft*RRR <br /> &'ACTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> Affixed with Its site identification number. The Tracking Sheet is to be returned to San <br /> JUAVUln Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. Ilir. noted below in responsible for <br /> Il ie that phi._ s fga is completed and returned_ <br /> FACILITY NAME: Puregro Comoany <br /> VAMITY .ADDRESS:_1904 W. Charter Way, Stockton, CA _ <br /> EPA Site #CAD 009109844 T <br /> TANK ID 139- Al 7 - i - 1 ,000 gallon unleaded gas tank <br /> *RRf*RR**YffR;R4YttY!lRYtfR!!*!tflf!*#R*t*R!R*tR*R*f RRR*R!*YYlt!**RR#!f#**!Rf**}lRRfRYRlYf! <br /> NOTION - 2 - To be filled out by tank removal contractor: <br /> 7lettk Removal Contractor: JIM THORPE. OIL, INC. <br /> 1leEr!resas: 361 N. Beckman Road, Lodi , CA 95240 <br /> Zip: <br /> Phone#: (2 , 368-675 <br /> Telephone (_)__Date Tank Removed, <br /> _ >E,�Y}YR*}*RYftRAY*R!*R*fYffffRR#RlRft;flflRR***t**lRYY**f#*R*RRYR}YRRR**YR#Y*RttlttRRltttlRf <br /> ViMON 3 -To be filled out by contractor "decontaminating tank": <br /> pada Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road , Lodi , CA Z195240 <br /> Phone# (209) 358-6 75 <br /> Aothoriaed representative of contractor certifies by signing below that the tank has been <br /> deCOntaminsted in an approved�manner as may be regulated by Department of Health Services. <br /> Vice-President. <br /> 3IGNA1lTITLF. <br /> RR*!#lRtYkYRf#Y;*ttRYR;lRR**R*R**Y!!R*RlRxttRRRR***YR**xYRt*R*f*RR***tRRt**ttxRtfxx*ttttRft <br /> 0=ION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> PRODUCTS Co <br /> rocllity Name 6MSTEE�neA BLVD.p�z�2 - <br /> 12Jv0 r <br /> ,.. � IIANCHO CORDOVA• ,� <br /> sic --___Zip: <br /> _Phone#: -- <br /> 4N1te Tank Received: ,` <br /> IZED SIGNA AND TITLE <br /> RRRRR##lRRRlYYRRYR!!!#fl;tRflRRYtf***KYR*Rf Rf#RR Rt*#!*RlRY!!!!*R#*Y!t#t!Y##feet*#RRY!!t!} <br /> "99 23 049 12188 <br /> ICIGIN() INS7R(XTIONS: FOLD IN HALF AND STAPLE. AFFIX PROBER POSTAGE. <br /> SAN JOAWIN LOCAL HEALTH DISTRICT <br /> 'r ATPN: UNDERGROUND TANK PROURM <br /> P. 0. BOX 2009 <br /> STOCK ON, CA 95202 <br /> a . j <br />