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SAN 1JaAC20_1 EV L.00„AL "W..AjrrH I S61IRI Gr <br /> U1DPRMOU1D TANK DISPOSITION TRAMINO RECORD <br /> #lRRRtlf}*!tt}Rt1t!!1t!!}R!t!lRRR#RRt}RRRXRRRR!}X#ttltRXR*RRARRAXRlRR#*!R}tR#}}}!R!#}tttlRf <br /> OWTION 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 /> Juaqu;n Local Health District within 30 days of acceptance of the tank by disposal or <br /> ro7°r.L!.ng facility. Jbc pgjd=of the nernit with number noted below in responsible for <br /> AIKVI M .-that this fo*® +s tiiRoa leted ,gW retUXned <br /> A'ACILIT'Y NAME: Puregro Comuanv <br /> FACILITY ADDRESS: 1904 W. Charter Way, Stockton , CA <br /> EPA Site 'MCAD 009109844 <br /> TPIalfK ID 139- I '?q � -� 1 - 1 ,000 gallon unleaded qas tank <br /> kA.RlRA#RW##tRRR#!##RtlRRRRtRRRt}AWR!!RlRR!*!tlXX*XR#RR*RRt!}*R#RR*!tR}RRR##!tlRtttlttftf!!R <br /> S&1TION - 2 - To be filled out by tank removal contractor: <br /> 1WMk Removal Contractor: JIM THORPE OIL, INC. <br /> Address: N. Beckman Road, Lodi , CA 95240 <br /> ZIp:,� <br /> Phone#: ( 3 68-6 7 <br /> °telephone: C 1 Date Tank Removed;____ _ <br /> RtIhRRRRRR#tl RRR!#RRR!!ltRRRlfitRt!*#*#R#R#RRRR##!#!#!*#RR!##R*R##tt!!Rt!!R!t*tttttttRttltt!} <br /> ff"TON 3 -To be filled out by contractor "decontaminating tank": <br /> '1'A9lkDecontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road , Lodi , CA Zip: 95240 <br /> ,._,Phone#: ( x:09 366-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> dw!o�insted in an approved manner as may be regulated by Department of Health Services. <br /> Vice-President. <br /> SIGNiTUtE AND TITLE <br /> ARRRR!!Rt}!YR#*XRlR!!#RRt*RRR#*!RR#R!'RR}XRX#W!!#W#*RRR##}RRlRRRlR**###Rl RRXXX#R##*##RRR#tt# <br /> 13I!'C'I'ION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address. <br /> Onto Tank Received: <br /> AUTHORIZED SIONAIU2E AND TITLE ������ <br /> RtRRRR#ttltlRR*R!RlRR!!R!R!lRRRRt!#*RRRlR#!#RtR#tAtt!#RR!!Rt}t!!!Rltt*#!!#ttRRRlttRt!!XlttR <br /> BY 23 019 12188 <br /> 1 ULINO INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JQAWIN LOCAL HEALTH DISTRICT <br /> ATTN: UNI)MCAMND TANK PROM M <br /> P. 0. BOX 2009 <br /> STOC7CT N, CA 95202 <br />