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SAN JOAQIIIN COTINI-V PUBLIC DEALTII SF.RVICRS <br /> ENVIRONMENTAL IIF,ALTII DIVISION <br /> t)Nl)FRGROtIND STORAGE TANK DISPOSITION TRACKING RECOIW <br /> ••••.r•r1r•+•••♦•••a••♦N••••a•••••♦a••+••••+••a••ra•••+•♦a••♦aa1N1a•1•NN♦♦N♦♦♦♦♦♦♦NNN♦♦1♦t•♦N44♦♦♦ <br /> St(:I'I(IN I - pobllc llealtlr Services Fnvhounteutal Ileaitll Division Tank Tracking Sheet !hall accompany each lank aMied <br /> wide Its she Idnulncadonnumber. The Tank 1'tnckiog Sheet Is to be renuned to Ihrblic Itealth Services Environmental Health <br /> Itivlllon within JO days of arceptanr-e of the tank by the disposal or recycling facility. The pennll holder is responsible for <br /> C11.41111114 that lids form Is completed and rchnned. <br /> FACILITY NAMP: Van De Pol Enterprises E.P.A. 0 CAC 002100064 <br /> I'ACILIIY AI)ORFS.S: 3147_S S. El Dorado St . , Stockton , CA 95206 <br /> 10 ,000 gaARrVIOUSTANKCONTENTS: Unleaded Gasoline <br /> LANK Ib I39 - _ ___TANK SIL[:_ <br /> ,.!•!••••••«•.••+•r•+•••Nrr••••aN•M•N••••+•NN+�♦••+++•M♦H1•a•aaH11+1a+N♦N♦♦NNN♦N♦♦•♦♦♦N♦M♦ <br /> SKt,l ION I - I be Riled not by tank removal contractor. <br /> Iank Removal Conttactor:_ Jim '1lwrpc 011, 111c <br /> Addrns: _351_N, Beckman lid./1'.0. Box 351 City: Lodlt CA Zip: 95241-0357 <br /> Phone M: (.209_) 360-6 I'l5 Date Tank Removed: <br /> 1♦•«•11.1H N••♦•♦•a•\+•N•a1+\aNH•N\+NINa1+♦M♦♦aNaNM11♦N11♦♦11♦♦/♦♦♦N♦♦♦M♦♦1♦♦♦♦♦♦♦*♦"♦'�♦*♦♦♦♦♦ <br /> SR(AION J - To he nlled out by contractor "decontaminaling lank": <br /> lmtk Contractor: Jim 11tor•pe 0110 Itte. <br /> Address: 351 14. Beckman lid./P.O. Box 351 City: Lodi, CA Zip.952111-0351 <br /> phone 1 209 ) 368-6175 _-- <br /> Andtmbrd tryne-senlallve of cmutador cettiryhrg tlunugh signature below flint Bre tank has been decontaminated In in approved <br /> manner as regahed by Cal FPA. <br /> Nmne 11Ue: Signature: bale <br /> ! 5A♦ . H♦ +\A•♦ H• ♦ «• a /•Ma • •+ •+•+1/ 11HNIa♦a♦•IAa1Ha ► ++♦+++ •• ♦ ♦ ♦♦♦♦♦ ♦♦♦♦�♦♦♦♦♦♦1 <br /> 1 al+k i s �i'ee or ate �1 Upa ant l�yc11•o�ar )on vapors treason elle Live �o S'r��inl� gr ee . <br /> SrIC ION 4 - Io he sinned and dat t y an ant or It repreunla lye of the treatment, et age, or spos aell <br /> accepting lank and/or piping. <br /> rncllity flume: Sclurl.t_zet. Steel 1'rcxlllct.s <br /> I20UU Folsom R1vcL Itancho Cordova, CA / <br /> Address:--------`— City: ZIP: 95712 <br /> phone A: t 916 l 9115- /r111U <br /> Ilnle I'mrk Rece.lved: <br /> Name: __ TIUe: Signature: bele <br /> •�•11+1µ+a+++•Nr♦Na+•+++++A+++\•a++NaI+N+N•+♦aaaaaaa+Nl/a♦a11NN♦++N♦N♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦1♦1♦♦♦♦ <br /> FII 21046 (Revised 9/11/96) Page 10 <br /> I <br /> l <br />