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• SAIV JOAC IlV LOC'�r• F-II~;ar.TH �I S�J:`E2I C'I' <br /> IWDERGROLND TANK DISPOSITION TRACKING REX)ORD <br /> !fl/RfRf#flfttf#lttf#Rttffit!!lRRflfRRRtRR#RRRRRlRtRR!*Rflff RtRRR!!f*tRlR#t!R#!lff Rf!#lRRR! <br /> SWTION 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. ThclLlnoted below is responsible for <br /> ensuring that this form is cowleted and returned; <br /> FACILITY HAMS: Coit Drapery Service <br /> FACILITY ADDRESS: 1146 Enterprise, Stockton, CA 95204 <br /> EPS sits # CPC Con 265553 <br /> `O <br /> TANK ID 139- 1 - 550 nal . unleaded aaso ine ank <br /> !ttlRf*R!Rltt!*Rf*tRRf Rttf!**tR*RRt*ttR***!t*tR!*Rf RttRtlf****RR***RRtRlfflRR#t!!Rlf Rf RR!!R <br /> SWTION - 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 95240 <br /> (:2Q4�_ <br /> PhoneA: 368-6 75 <br /> Telephone: ( ) Date Tank Removed., -5-1151-20 <br /> RRf RlfRfltRt**#tt*R****!*t!**t!*f**R*ttRlR****Rtf RfRR*#*f!R#R!R*!!*RRRlf if RRR*tRlRf lRtRRlRR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor-Cal Oil , Hauler of rinsate <br /> Address: 351 N. Beckman Road , Lodi , CA Zip: 95240 <br /> Phone#: (209 368-6175 <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 /> Vice-President <br /> SIGNATME X14D TITLE <br /> RfRRtRlRRRR!**!Rtlf!**RRlRRR***f*!!*RRR*t!R**RlRtRR!***lRRtt*t*!*tt*fi tR*!*!***!f#**tR*ttR#t <br /> SIMON 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name SrhniLze r Steel Produr s <br /> Address: 1Pnnn Fnlsnm Rlvd , Rancho Cordova, CA 95742 Zip: <br /> Phone#: (916) 985-4810 <br /> Date Tank Received: `s�- 7 .) <br /> KkAd <br /> ALMMIZED SIGNATURE AND T <br /> *RRfflR*R!R****!R****RRt****tt*f Rff***!**!*R*tRf RRltflR !f*!!!*Rt*!*RR!*lftR#*RR##tf*RBBB <br /> LN 23 019 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALE AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />