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�iAN ,7CJACiJxN Lc�� f-I�'.?�1C,2'g-I�fSSS�`F2xC'i� <br /> L14DER ROLIND TANK DISPOSITION TRAIXINo Rsc RD <br /> !l!!!tlARl3trtfYfRAlt!!R!k*ttttRAfRr'lRtRRtRAtttRRfkffiRAktARRRfgtFRRB*RRRtRRfffitRlRRRfRffiRRAlttf <br /> IMMON 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 /> Joaquin Local Health District w,thin 30 days of acceptance of the tank by disposal or <br /> rscycling facility. TbL-ho'd r of the yeyjL vl h <br /> .��,-��"�'�ihS�forty .Ss C�Dleted arcl r��ned r VQZCd 2glov la reaoonslble Eor <br /> FACILITY NAME: Largin 's Se„vi e <br /> 1'AMLITY ADDRWS. 2235 ChercL,-j Rnad• St�>c l;on, CA <br /> TAW ID 139-��)� 4/ tank EPA <br /> lRlRtRRRtt**RR#tf**ttRttgRYlR*RltRRtR*t*tt2RRRRlt!*RtARI$RR RRR Sir.(, <br /> (, li tlltt!!2?308 R <br /> 2 - To be filled out by tank removal contractor: <br /> hvtk Reroval Contractor: JIM "HORDE OIL. INC. <br /> AIldress: 3' i 'J. 6eckrjn Road, Lodi , CA 0'S^40 <br /> —.- zip:. <br /> (c 3 68- 5 <br /> TWephone: ( ) _ _Rate Tank Removed:117 Z lkq <br /> R!AltttRRRRtltRR**BFR#RtRftf#RtY*fRtffiR*#!RRlA*FkRYffi!!R#Rt*!RffiAARRtlAlR*ARAftAAtltR!!!tffiFAt! <br /> AMON 3 •To be filled out by contractor "decontaninatibg tank": <br /> To* rMCGotaisinstion" Contractor: JIM THORPE 0IL, INC. i Nor-Cai Oil , Hauler of rinsate <br /> Anldresix i51 N. Beckman Roan , Lodi , CA Zip: 95240 <br /> —_. Phoned: <br /> (2197166,-617 <br /> Authorized representative of contractor certlfles by signing below that the tank has beer. <br /> " 40040asinsted in an approved manner as y be regulated try Department of Health Services. <br /> Vice-President <br /> IGNA MM TITLE <br /> RRtl14lt1RffitlRttRRlf*RtlRRRtRRktRAkRkRRR*kRf*R*#RtltRR*RRR*RR#RRRt RR*Rt*R RRlRRRRR!'#t}ftkl R! <br /> AWTION 4 - To be filled out and signed by an authorized zepresnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> facility Nae.e <br /> �..�^ SCHNITLC�T'&CL --- _—__--. -- <br /> Adkese: 12000 FOLSOM BLVD. <br /> �anmcHo C[1RDOVA, CA 95742 Z1F: _ <br /> We Tank Received: ///1 — -------�__. <br /> AUTHORIZED SIGNATURE AND TITLE <br /> �"RAFtRAR*k*YlRRARRlttRRR*RRlRtlfRttRkRR*RhRRfRARkR!!RltflARtlRRR*FRttlARlR#*t!*!f$!!tlRRtt! <br /> ON 23 0/9 12/11 <br /> AII.LW INSTRUCTIONS: IF'= IN HALF AND STAPLE. AFFIX PROPMR POSTAGB. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TAW PROMAM <br /> P. o. HOX 2009 <br /> STOOCTON, CA 95202 <br /> 'S <br /> r <br />