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SA.v dOAQL-IN coLVSY FLBLIC HEALTH SZMVICES <br /> LNN7ROr3iEYT.I L HEALTH DWISIGN <br /> L-rDERGROLivD STORAGE TA.`t&DtSPOSITiON TRAC.--%M;G RECORD <br /> ..rY.++Ya.YrYx+rxxxrx........xa ........ Y+ro..r:.aurrYrxY+x.f <br /> SEmON 1 .public Heaih Ser+ic" Eaviroamenotl Health Dhisioz T=k T.-aeking Sheet 31=R accompeoy ach tank Iffmd wir" <br /> is sin:can Mcatan n=ber. 7=Tacit T:x'c-.g Scat is to be:etat`td to Public HC-;It S'''cls ==t'iron.:.mtai Heath DivWafi <br /> w•rtiin 41 dw!s of zce=M=--of he tank by he disposal or reeictiag tac:ltry- Toe perrcit holder is :espas:ble:cr r.�•urr.;Z7; <br /> OW 'Or-- is eompL--ted Aad:etur-ec• <br /> -XCILITY N.iM=: San Joaquin Countv Mosquito & Vprrnr Control n; qtr; nt <br /> 200 N. Beckman Rd. , Lodi, -CA. 95240 <br /> FACiL1TY ADDRHSS: <br /> -A..i{ID 3:39- �.r0.NK SIZE: 000 ?RTI, Us T.AAic COv n.N'TSA l�r <br /> •xx...Yxwxs...w.x..x.rY..+rrxxra....rax Yrxxwxxaf,wrx...wY.:xr..Yxxxrrxaxwxx+.:a,a,Y>w.........+:.x.............. <br /> SECTION 3-To be -Z!ed out by rank removal cane actor: <br /> Jim Thorpe Oil , Inc . <br /> 'nee 2emcvat Coatraaor: <br /> Addt�s: � 'w ' �^ <br /> P.O. Box 357 Ctty; Lodi, CA Zia:_95241-0357 <br /> ?hone.: r 209 ) 368-6175 DateTank'.tz—aver: / <br /> .Y.arwrrrxrsYMraxwY#w+Mwrrxx+ .xr.....e.r..xxw�MR..�a.Y+...aY.++..r.�.a.....YYrw:aYYr!x x.:w................. <br /> SECTION 3 -To be J,11ed out by coutmetor"decon=minating tank': <br /> T,ak Decontamination Coz=zctor: JIm Thorpe Oil , Inc. <br /> Address: - <br /> P.O. Box 357 City:Lodi , CAZi?: QF2n1_nas7 <br /> 209 368-6175 <br /> Authartred represaatadve of contractor czr;ify'.ag Roush siaaarra'aetow r.�at r a:aaYhas =desonraminaxd _an apProvrl <br /> r-M-4r as rGt fired by Cal EPA. <br /> ,l,tic; Martin Thor e Title: Vice Pres. 5ignacue: <br /> Date �'oZ d <br /> rrrf Yarrrrrr.Yy:xrrxrwYrarwrra..Yrarxt.xw.Yw.+Yw>.n::n.w.++.r..rrrar.+rYr..a:vrrr.xxrw.e.xxxrrxrrxx+rxr.w.` <br /> SECTION 4-To be lig wAhorsed representative of the c anent. sccrageor disposal Iaciiin' <br /> acnepra, <br /> Far.'ir: Name: WEST COAST E P <br /> 1221 S Tegner Road City Turlock Cn Zip: --g5320 <br /> Pione ( 209 ti 668-9378 <br /> Dam Tark Rzceived: l) <br /> Tctl-: Sig:Zc re: Dace <br /> Same: " <br /> ..ra.r YYxNrl:xf>'.xar.:RIxYYYfYr#.:..•aa.:.H.}.Y.T.T.T+.a1:.lYYnYu..rY+YYr.Y YxY: Y ML./:r <br /> .yvAif Ywixflrr:I.xYYxttfrxf Y <br /> iced C8r 13199) Page ]0 <br />