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SAN AKQUIN COUNTY PUBLIC HEALTH SER*,CES Yli I 0 <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> #►+tw#»++*#*++++rt# riw� *s►ir+�+++�' i�`t##++Wrtrt+s**i►+w»w+itrt##ws#tiw+W#+»##+*+»++iW <br /> SECTION 1 - Public Health Services Envi hmental Health Divisiodl�ank Tracking Sheet shall accompany each tank affixed with <br /> its site identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division <br /> within 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring that <br /> this form is completed and returned. <br /> FACILITY NAME: San Joaquin County Mosquito Abatement and Vector Control <br /> FACILITY ADDRESS: 200 N. Beckman Rd. , Lodi, CA 95240 <br /> Pi ung onl�yp ��♦� •��: Oil and Gasoline <br /> TANK ID#39 -� "TANK SIZE: ' _PREVIOUS TANK CONTENTS: <br /> ►i»twwwrt#»###+t#»Wi»irtWW+wi##*#+ti#»+»#iW»»tiWi#hi#iWtiWWiiiWi++»W++ii+Www#i*iW+wWwi»i»++»+++Ww+#++i+»»#»++ <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Jim Thorpe Oil , Inc. <br /> Tank Removal Conracmr: <br /> Address: P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br /> Phone k: ( 209 ) 368-6175 Date Tank Removed: 11/30/01 <br /> w#rwtt#twWiwisw►+i►wiiiwrt»t+wwittttst#sur»##*##si+rrttt##tri#t+t##+#+t#rtw#Ww*rtrtwwwWWw+W+Wish»++t#»#+#rw+W#i <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination Contractor. <br /> Jim Thorpe Oil , Inc. <br /> Address: P.O. Box 357 City: Lodi , CA Zip: 95241-0357 <br /> Phone k: ( 209 ) 368-6175 <br /> Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved <br /> manner as required by Cal EPA. <br /> Name: Martin Thorpe Tide: Vice Pres. Signature: Date 1/17/02 <br /> rttrtii#i#»»WiWWii»»wwiirt#rtw+rtrtt#rtwirttt##iit»#tt4wwwtrti#trtwwt+wrt#t►WWwiw»###ii+#it►##**+*#www►+i+i»##***#+### <br /> SECTION 4- To be signed and dated by an authorized representative of the treatment, storage, or disposal facility <br /> accepting tank and/or piping. <br /> FacilityName: Forward, Inc. Landfill <br /> Address: 9999 S. Austin Rd. City: Manteca, CA Zip: 95336 <br /> Phone p: ( 2na ) 992-4998 <br /> Date7kffiAtltZrdS :Fibas Pipin 0 Received: 01117,/RV <br /> Name: ` Title: Signarure- Date <br /> st►i#i+#►i+i»####»+i»►WW»+i►##►iwrt iwiffsftt int#»#rt###+#r#w*#iirwww+WiiWi+#+wwi+►W»»ti*www+srwWiw»#i+w# <br /> EH 23 046 (Revised 10/19/98) Page 10 <br />