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SAN .70AG _"IV LOC`�r• HMAI rrV >IST'R3:C,r <br />UNDERa;OIM TANK DISPOSITION TRAQQNO REODRD <br />tRRRR!#!R#f!t!t!R!R#!R!#RR*R*RR*Blit#R**RR*R*RRR!lRRR!**#!ltRRt!#RRR**RRRltRttt**flRRtf##R! <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 <br />recycling facility. The holder_ of the cerwit witl+ num`�r no a.� h. by disposal or <br />ED>ft1r1_na that this ford 14 lw is zeswn�sihtn fnr <br />FACILITY NAME: Color <br />FACILITY ADDRESS:_ 5400 E. Harney, Lodi, CA 95''40 <br />TANK ID 839- _ C)� <br />tl#!t#RRRIlRR!#*R• *R!l!*R#R#lIRRlR**ltRtRtt*R#RBBB*#RRRRR*RRA**R���R*RlRRRRRlI*R*!R*R!*R! <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor. JIM THORPE OIL INC. <br />Address: 351 N. Beckman Road Lodi CA <br />ox Lodi, CA 95241-0357 Zip: 95240 <br />Phone#: (209) 462-4581 <br />Telephone: ( ) Date Tank Removed:_ <br />RRR!*!lRttltR***ttR*lR*t!*tR**#!*RRR*R'�#R*R**R"t*t##R*tllR*IRIRR*RBBB*R!*!!*lRRRRlI#!*tllR#! <br />SECTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: lktt,4 �- wC y/e - (E,C ka k,& • e) /urn,__7t- <br />Address: <br />ip: <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved 17 as may be regulated by Department of Health Services. <br />*!*tttRR**!R!*t*t*#!!*tt!*tt**ttlRR#!**GN***TL*R#t*lAND <br />*ltxTElRRR#lRRxRR****R##*#Rtt#tR**t**R#*Rt <br />SECTION 8 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Nam ROEE� <br />Address: _ r' -o. .� ZLt7 L-ozi <br />Date Tank <br />Zip: C iSZ f a <br />N: (iL )334--3A47 <br />AUTHORIZED 3IQNAT m AND TITLE <br />lRttR!#**t!*R#****!!*ltttltit!!t!*t!t!*lRRltllllRtlt!*ltR*tR#*!tR!*!*RRtttltR*tltR#!#*lR!!t <br />!H 23 019 12/88 <br />NAILING IN37RUCI'ICKS: F= IN HALF AND STAPLE:. AFFIX PROPER POSTAGE. <br />SAN JOAOUIN LOCAL HEALTH DISTRIcT <br />ATTN: UNDERGROUND TANK PROGRAM <br />P. 0. DDX 2009 <br />STOCKTON, CA 95202 <br />