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SAN JOAV Tlk4 T.00,A f-rMAI.TI.- '7I SZ'E2I CT <br /> LWERGROUND TANG DISPOSITION TRACKING RECORD <br /> ltttttRlRttRR#tRRlf#t#!!#!!xltxf#!xRlxlR!#xRxtklfklxxRx*lRxtR!ltRRxRxxR*#x""t!!tltRtltRRklR <br /> SECTION 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 within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permit with n vnlwr nnrn� •.�tnv <br /> ensuring tit this fo m is omn�lete,�ani *•r„r.,a.�, <br /> FACILITY NAM: MCI TELECOMMUNICATIONS CORPORATION <br /> FACILITY ADDRF_SS•28499 S. Corral Hollow Road, Tracy, CA <br /> TANK ID #39- EPA Site # CAC 000175933 <br /> t!xltttxt#!!#R!#xtixltxxlRx!#tttxx#ext!ltlRRltxtRxRRRRRR#x*!"xRR""kR"f"""RlRx!lRkRltxRRtf tR <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Road, Lodi , CA Zip: 95240 <br /> Phone#: (209 462-4581 <br /> Telephone. ( ) Date Tank Removed: <br /> RRRxRltRRlRt!##tx#xlRRlRxx!*RlRRlxx#t*RxxR**RRRxxtRxxRkttlxRtxtRRxRkR'tfltx kxRkttRxltlxxkxlxf <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Hauler of Rinsate <br /> Address: 807 E. Black Diamond, Lodi , CA Zip: 95240 <br /> Phone#: (209) 462-4581 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> *RRRRxtRxlxxRRxx!!#xxlxxRRRxlx*x##flRxRRlRx*RRRRx#!kR*xxRxlRx!###*#xxltRRx!##!#*R!!###xRxx! <br /> SWTION 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 /> Zip: _ <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> tttt*!RR#x#RxxltlRxtlxRf RRxxxxRx!!*ext!!!x!!*!RlttxR!!*ktR#x!!t!x!t!R#x*R!lktxxtx#Rte#RRkxR <br /> LN 23 019 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> S OCKTON, CA 95202 <br />