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PU13riC I=Il: 1.rI1II S1; VICLS ,.1,G <br /> SAN JOAQUIN COUNIY :t <br /> YOGI KIIANNA AID..M.P.H. <br /> Ilcahk 011 ren <br /> P.O. Ihnx 2(X19 a (hail Eam Ilaxchmn AP(Illlc) 0 Slocklou, GIIhMnlx 95101 r4I) eAA� <br /> (209) 4(A ltW <br /> DNDFIIGHOUND TANK DISPOSHION ]HACKING IIF,C011ll <br /> S19(1ION I - Public 1lenhh Services'Ilack ing Sheol will accompany each lank allixeJ will, Its Silo Identification number. 'Ilio <br /> ilarklug Sheel Is to be relmned to Public Wallis Services uilhill ju lint;of acceptance of Ilio lank by Ilio disposal or recycling <br /> facility. 'Ilia pe.uJl holder IS lesPonsible for ensuring that this linin Is coulpleled slid returned. <br /> FACILITY NAME: Valley 'Wholesale Drug Co Inc G �C � 001022416 <br /> FAC'ILTLY ADDRESS::( 1401 W. Fremont St. Stockton CA 95203 <br /> 'IAMK 11) X39 • I UZ,C)'Z— 'Tank Descripdun: 1 ,000 gallon gasoline Tank II (90 <br /> SI:(-A if IN 2 - 'To be filled (list by lank removal andlactor. <br /> 'lank Removal Cunbnctor: JIM 111010E OIL, IIIC. DILA RICII-MART CONSTR. <br /> Address: 351 N. Beckman Rd. , 11. 0. Box 357 Cloy: Lodi , CA �f Zip: 95241-0357 <br /> rhuue q: ( 209 ) 360-6175 Dale Tank Itenroved: <br /> SI?(Io b <br /> oO I - fit BIIed ant by cunlinclur "decontaminating lank": <br /> 'lank Deconlamdnadon Contractor. Jill IIIOI1PE OIL, INC. DBA RICII-MART CONSIlt./Nor-Cal Oil <br /> hauler of r nsale <br /> Address: 351 N. Beckman Rd. , 1'. 0. Box 351 City: Lodi , CA Zip: 95241-0357 <br /> Phone #: ( 209 ) 368-6175 <br /> Aulhorlted replesentndve of conhnclor cendiied by signing below dial the lank has been deconlamlinaled lir an approved <br /> Innaner as required by the Slate Department of I leallh Services. 'n <br /> Signnune: i l \fin Cw w � •1111c: 1 <br /> • •• •• .• ..... •• •.. .•..•••. ,.••.•••• •.••.•...i•••.•.••. • •.•••. ••• . •••.•..•..... •••••••• <br /> rank (s tV4e oY all stuc�yes atnd1lydrocarLon va`rors upon $cllvery to SrctIII zer l�iPyr <br /> SECTION 4 • 'I'll be signed and dalcd by an nulhoriced represu (alive o the Iceaunenl, storage, or sposel facility <br /> accepting lank and7or piping. L <br /> I'ncllhy Name: .li� S — G/ylG'.'_ <br /> Address: City: <br /> c <br /> Dale 'lank Itcccly A: � <br /> Slgnahna: <br /> 71ife: r t <br /> •..........••.•.••••........ ••......•..•. ........................••...•.•.••.•.••••••••..u••�•••..••••. <br /> rage 10 <br /> I" 21 069 (Rev 2/a/91) vp /I <br /> A IN•1eMn d An Jm.pdn Galion 11c.111,fit Stn@a <br /> \� <br />