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SAN .7oAC iIN L0C7�L >tF ar.TH DIS�!'F2IC'1' <br /> UNDERGROUND TANK DISPOSITION TRAQ(INa RECORD <br /> !t!!ltltf ttftRRflR!lRf R!lRRR!*RRRfR*RRRlRtRlRR*R!*f*Rft*R*tR**RRRtlRRf**!**tRf tRfffR*tt**!! <br /> SECTION I - 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. Tb€ hLQ1der of the permit with n nfna* noted <br /> below is responsible for <br /> eaaurina that this form 1R o�lete returnees <br /> FACILITY NAME: Coit Drapery Service <br /> FACILITY ADDRESS: 1146 Enterprise, Stockton, CA 95204 <br /> TANK ID 139- - _ 1 - 55n nal . unleaded naspJinetFankCPC 000 265553 <br /> tR*!R*R!!R!lRttlflRRtRRflRt!***RRRt*t*RtRtltRRR*lRtR*!RlRf tRRRR**RR*RBBB****fR*!fR*RlRf*R!f <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 95240 <br /> ((:207Y <br /> Phone#: 368 <br /> 611F) <br /> Telephone: ( ) Date Tank Removed: <br /> RRlt*t!*ltRtl!#tt#tRf*t!R**t#!RR!#R**t#filRRlRRff*!!ttlRlftRtRRR*RR*RR*!R**RtRRf ttRtf Rf*ltfR <br /> SEC►'ION 3 -To be filled out by contractor "decontaminating tank": <br /> Tads 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 /> SIGNATURE AND TITLE <br /> SECTION 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 /> AWHORIZED SIGNATURE AND TITLE <br /> IfRR*tRRRlRtf t*R!R!t!*RRRRR!lRtfltfRlt!*fi**fR***!*fRR*RtlR!!Rf lRRR!*lRRf RRf t*RR***RfltR**** <br /> CH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALE AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOApUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCICTON, CA 95202 <br />