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SAN 10AQUIN C004TY PUBLIC HEALTH SERVICES <br /> ENVIRON-NMNTAL HEALTH DIVISION <br /> UNDERGROLNTI)STORAGE TANK DLSPOSMON TRACK NG RECORD <br /> ###•.iw/WwWTTTTw/##WM1W}WIWWWWWW##iiW#WWWW Wifi#fiWWTi#iW#1.Wi#4fi#TT#W#YYF!FWTTwWTTWWY+.Y#YWwT�##}iWW#T W#W�Y#wiwf <br /> SECTION 1 -public Health Servkm Environmental Health Division Tank Tracking Shoe,shall accompany each hnk affixed with <br /> its size'rcifl=-ion number. TEc Tank Ttrc.;on&Sheet is to be returned to Pubi:c Heaitb Se-vices Envlrommental Health Division <br /> withie days of acceptanx of the tank by the disposal or recycling facRlry. The permit hdder is responsible for ersuritiZ tint <br /> this form is completed and retnrred. <br /> �4CILITY NaMc: San Joaquin County Mosquito A V rtnr Control ni stri c_i <br /> --20f}-Id—Beekmalr-Rd. , Lodi, CA 95240 - <br /> FACILITY ADDRESS: / <br /> q%!j_TANK SIZE: OOC EVIOUS TANK COTE-NTS./7K�y 1 <br /> iiTw Ti###f#f##WT#T#Yw1.}.TWTTWfi#'s#TTIYYpWaY'iff.#Y11111tWWf#fY#WWT#}W#WWWWTlMWWWMffi#WiFW###fiaT/rtWWWWW#}wwwnJTwT <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Tacit Removal Cactrruaor, <br /> Jim Thorpe Oil , Inc. <br /> Address: P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br /> ?hone x: ( 209 ) 368-6175 Daze Tank Removed: `)�CM6 <br /> •#WW WW uif WfMWWWi:#Y#WWIWTih[YeY#WWWT#fM##iTW#WYY�wYTwwww W/#wW#WYwW+H/WWW#rtWWWWi Wfiv-lliWWaT#W WWWWxiiw'#M.#if.#wiW## <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: JIm Thorpe Oil, Inc. <br /> Address: P.O. Box 357 City Lodi . CA—Zip: <br /> 209 368-6175 <br /> Phone:f: (_� <br /> tifying through signature below t.�x the tank has bent decontaminated is an approved <br /> Au[hocized rccrescatadve of cxtrac:er cer <br /> manr=as t=ruired by Cal EPA. //JJ <br /> ;Yarn•.: <br /> Martin Thorpe T+rte: Vice Pres. Siguavue:A . Date-4 <br /> WW W iae#wYWI1 WW W iiWWi#Wx}WWWW##Wsif incl(#WW#WW WT.fY#iw WW WW WWlYwiW•.TrYiiW W Wwf,fYi Tw Y#L'R#WWWW WfW�!liWYWW ii#W f##ww#Yf• <br /> SECTION'4-To be signed cd dated by an audtorti ed represmtotive of the ¢eatment, storage, or disposal facility <br /> act =I-alf�lffid(,M• IXXX FOR USED OIL STORAGE <br /> re� J�1 <br /> NC we--ZA- co-" <br /> Facility Name: <br /> Address: <br /> X51 N B64wi Rd XLZ l cam. (�� �d i <br /> Crv: Lodi CA Zip.-, : 13x240 <br /> Phone : <br /> Dam Tank Received:Same: (] <br /> /,, -,.I Title: Signacsre: Dace <br /> wTn.YiliiWif!#iW Wfi}W#fiGWTTW xWW#WW#ffsTMM##WW YwT#T#/'iwWWTWW#W4aiwsWTf WW iW. Wa.WWW'WWwi}afwWWWWW#Wiiwii'##Tf# <br /> Page 10 <br /> .1:20e6 (Revised C8i 13!99) <br />