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FROM JIM THORPE OIL, INC. FAX NO. : 209 368-1851 May. 20 2004 01:06RM P1 <br /> , / <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> ♦is;;fir++iitsiit#witartt#wwikttiii#Wii;ittVirt#iirttt#rtWWiiti#iiiiritit#Wir#aafifitrt#i#arts#a#�a�tirt#WRtafiiWWf <br /> SECTION 1-S.IC Environmental Health Department's Tank Tracking Sheet shall accompany eaeb tank affixed with its site <br /> identification number. The Tank Tracking Sheet is to be returned to the Environmental health Department within 30 days of <br /> acceptance of the tank by the diaPncal nr rr.yrling facility, The PWro.k holder is roopultoiblc rut cuswtltb Thal dns rorm is completed <br /> and returned. /�y� q <br /> FACILITY NAME:- 6r1C/W19 <br /> FACILITY ADDRESS: ..Z(/ S /SI6-Me9vul ZBD/ <br /> TANK ID 1739- ..&ANK S17.F: SCJ tJ PREVIOUS TANK CONTENTS: <br /> ;Wss;sfii#iw+#s.rstt#W+irrraaW+++iratttrtrtsrtfrtttwwwiiirtrtf wrwirktirtiwrtwwwrtrtfiWWrr+tirrfitw+;satttiW#as;#i###k <br /> SECTION 2-To he filled out by tank removal contractor: <br /> Tank Ramovol C-nntraotor. <br /> Address 7 <br /> _..�/ 7 F. City: lip: <br /> Phone#:( �% _ T 4 p6 7 S Date Tank Removed: <br /> ifirfiµYattsarfirriWittiiitfi#ww#tttttii W#iwistrifi#rtit+iatrrf WWwrriisttwMWi#ttfirrrrtW;;artrra WRit;ifiittatttit <br /> .SECTION 3-Tn hr.filled not by rnnii.W,M�ar ttafoanWminuKn6rapk": <br /> Tank Decontamination Contractor: <br /> Addrets;—(�;-=„_� C�C:�CfC`ti9 ,(, City: zip:_ P } e— <br /> Phone#:{ b (f— 6L7 T <br /> AuthoriC.od reprwOntnt!YQ or."u4 rlul ucalrying through signature below that the tank has been decontaminated in an approved <br /> manna as requiredbyCad EPA. <br /> KZn/ eeol441 Signature: Date <br /> wWW#W;aart4ww+WiiaaWwWw#aratWWiairi Yatwwi4taa;##iiwtr#fi#wWWaaatatWWiµ+aaafiart r+aWtaiit+raa+kifit+fa;i;;ty#taa <br /> SECTION 4-To be signed and dated by an authorized representative of the treatment,storage,or disposal facility <br /> accepting tank and/or piping. <br /> Facility Name:, Sl' Z& sr e-� <br /> Addrece• /7/h ,[l�.�LLm�J GGA ctry97 CO�/Lp <br /> Phone#: <br /> Date Tank Received: S <br /> Name-1w:9 46tl'M[I Titic: W Signature: ! Date Vl p <br /> rt##;tiiNWriiiwYWWwksiWttiatrtrt+tit;twW#tifiiWwwitfWWWii;fftWr#tiitii WrfitWf;;rrt##iis;rtikfaa#W##i;iwisata <br /> FH 23 046 (Revised 10/16/03) Page 10 <br />