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Nwe a <br /> SAN JOAQUIN COLNTY PUBLIC HEALTH SERVICES <br /> ENNTROiv'_KENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANS DI.SPOSITTON TRACKING RECORD <br /> rtwwvT«vr.ww+W rrYyawwy}syi}wwwwiiiiii#WW#Wf#ww#wixNx####W#s+ir-.rwwww++www#.w#wwwvr#virrw##wWWWwxwixNix#ix..w <br /> SECTION I .public Health Services Environmental Health Division Task Tracking Sheet shall aceotapany each tank affixed wit, <br /> its size identificatton number. -,--Tank Tracking Sheet is to be retuned to Public Health Services Eavironmentai Health Di% sioa <br /> witttfa 3f1 tins of acccptaace of the tank by the disposal or recycling facility. The permit holder is responsible for ensuring titat <br /> thu form is completed and rettimed. <br /> �ACILITYNAhIE: San Joaquin Count Mos ui Con <br /> trol Distrial- <br /> 200 N. Beckman Rd. , Lodi, CA 95240 <br /> FACILITY ADDRESS: <br /> -ANK ID R39- b\$ Q TANK SIZE: A>C>0 VIOUS TANK CONTENTS <br /> ia#+.Ni#i#ifisisw#w#WMYr.1:.#w##Mwrwrwr#w#WwW#wiNNikkWwwl W##i#Wwiw.iW#wWw#iiwi#iix##ifw#f#i#Wr+i#+#rt Mw«••r+.rwwn <br /> SECTION 2-To be filled out by tank removal contractor: <br /> Jim Thorpe Oil , Inc. <br /> Tank Removal Contractor <br /> P.O. Box 357 City: Lodi, CA Zip: 95241-0357 <br /> .address: <br /> Dion x: ( 2 09 368-6175 Daze Tank Removed: <br /> v.#YY#la WiiiwWwW#siiwwww Ww}##i#wi#Yri+rrrr+w#wWwiwrY•'#+HMaiws#iirwr+aiwrwwW Wiw#wi+Mwisii#WWWwi#iiirils#i###W <br /> SECTION 3 -To be filled out by cotdrector"decoraaminating tank": <br /> Tank Decontamination Contractor: JIm Thorpe Oil , Inc. <br /> Add:rsa: <br /> P.O. Box 357 City Lodi , CA—ZiP aa2A' _Q3-9 <br /> 209 368-6175 <br /> Phone d: (�) <br /> .4ulborted representative of contractor certifying through signamre below Liar the tank has been decontaminated is as approved <br /> manner as required by Cal EPA. <br /> yazn.; Martin Thorpe Title: Vice Pres. Signature: <br /> Date <br /> w#iY%+wW#WwwiiwwWww##11x11#Wiiiv}=#ivW#WWrrr+r+iW#wwww#r..#:riw#Wwwww+eN*iiaWsiWiwxi#www+iii###WwWi.#i.#iiv% <br /> SECTION 4-To be signed and dated by an audtorked representative of the treatment, storage, or disposal facility t <br /> accepting tarpai(d/ffir?("060 FOR USED OIL STORAGE �OVe <br /> Facility Name: JIM L, INC. CJQ�, G6A <br /> I I I,, I A <br /> � 4�3�0 <br /> A;d ,; 351 Beckman Rd. �u� <br /> s.�e� t Rd city. � ,- zip: <br /> Phone#: ( 2091 46fl--69 75 (e (�,$ <br /> Date Tank Received: <br /> Name: <br /> Title: Signarsre: Due_ <br /> WT«%.iyx}sYaWYYw#iwriwwWlxx#aeF#Yf+Ysii###wxiaTY+r+Yw4wTYYYrYr#.YW,MWNWfi#*:awN.w##'.xw#ii#iiwwiW##Y#s�rrwifs% <br /> EH 22 046 (Revised 08;13!99) Page 10 <br />