Laserfiche WebLink
s2uLl JO.- 2UILV L.00_,Ai� 1iF.AI�7" 172STFt=CT <br />UNDERGROUND TANK DISPOSITION TRACKING REC)ORD <br />SECTION 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. The holder of tha permit with number noted below is responsible for <br />ensuring that this form is completed and returned <br />FACILITY NAME: PANE IA TRUCKING <br />FACILITY ADDRESS: 2150 E. Fremont Street, Stockton EPA Site # CAC 000159381 <br />TANK ID 1139- 1109 - 02 $—�Dn{.0 �p OiL T4Kk <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Jim Thorpe Oil Inc. <br />Address: <br />n Road <br />#: <br />Telephone: ( no 462-4581 Date Tank Removed: 6/13/89 <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />p: 95240 <br />Tank Decontamination" Contractor: JIM THORPE OIL, INC./Nor-Cal Hauler of Rinsate <br />Address: 807 E. Black Diamond, Lodi, CA Zip: 95240 <br />Phone#: (209) 462-4581 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner ?s may be regulated by Department of Health Services. <br />Vice -President <br />J✓ 51LAWIUlE 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 <br />Address <br />rr,�� 91 <br />Date Tank Received: % % Q_/ <br />AUTHORIZED SIGNATURE AND TITLE <br />EH 23 049 12188 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />