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SAN O QULN COUNTY PUBLIC HEALTH SE9110ES <br />ENVIRONMENTAL HEALTH DMSION <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION 1 - Public Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank affixed with <br />its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br />within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br />this form is completed and returned. <br />FACILITY NAME: <br />snil7A 11 1.1— <br />FACILITY <br />612 W. 11th St., Tracy, CA 9537 <br />TANK ID #39 - \ TANK SIZE: 7,500 PREVIOUS TANK CONTENTS: unknown/diesel <br />SECTION 2 - To be tilled out by tank removal contractor: <br />Tank Removal Contractor: JIM THORPE OIL, INC. <br />Address: 677 E. Lockeford St. P. 0. Box 357 City: I nrii . CA Zip: 95241 -03 57 <br />Phone #: ( 209 ) 368-6175 <br />Date Tank Removed: September 14 2001 <br />SECTION 3 - To be tilled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: JIM THORPE OIL. INC. <br />Address: 677 E. Lockeford St., P. 0. Box 357 City: Lodi . CA Zip: 9 5241-03 57 <br />Phone /f: ( 209 ) 368-6175 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved < <br />manner as required by Cal EPA. <br />Name: Martin Thorpe <br />- To be signed and d9ted by an <br />accepting tank and/or piping. <br />Facility Name: <br />Phone #: <br />Date Tank <br />Name: S <br />Ci. 4,ni+mow C+ool Drnilnr+c <br />12000 Folsom Blvd. <br />air I Gorr-aRl tl <br />Rancho Cordova, CA <br />City: Zip: 95742 <br />Date /0_4_9 1 <br />EH 23 046 (Revised 08/13/99) Page 10 <br />