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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI(V9 ENVIRONMENTAL HEALTH DIVISION UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD +444#:+♦#4+t#4##1tr411♦/1++ffl4f!#}a}rrAfl+ff#ra#+##rrf+larrflr4r11+arraarilairfrrrrrafilNifiiNffiiffMil SECTION 1 - Ihrblic Health Services Environmental Health Division Tank Tracking Sheet shall accompany each tank Affixed with lu site Identification number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Health Division wUhln 30 days of acceptance of the tank by the disposal or recycling facility. The permit holder Is responsible for ensuring that this form is completed and returned. FACILITY NAME: Hutchins Street Square C.P.A. p CAC 001239520 121 S.. Hutchins Street, Lodi. CA 952A0 FACILITY ADDRESS: TANK IU N39 - TANK SIZE: 3,000 ga11ot1gtEVIOUS TANK CONTENTS: (l4 bunker oil 144«+}•44«4+#+a+44r}♦#4#rrr#44#fff}#«##IIf1»#41f44#}♦1♦rr4rrf}+#►1+rlflrrarMlr#rrfrffiifi/ffi/ffifiilfr►ff SECT ION 2 - To be filled out by tank removal contractor: Tank Removal Contractor: Jim Thorpe 011, Inc.— Address: 351 N Beckman Rd./P.O. Box 357 City: Lodir CA Zip: 95241-0357 Phone N: ( 209 ) 368-6 17 5 Date Tank Removed: 4!a#«1NHf##4r}}##41#4}+♦44fNtl4+Ill}4##1#+fM1#r}4#rMMMa44r4N#rtflrrfa!lfrllrlH4Ar+f 14+f++f Allalar♦ SECTION 3 - To be filled out by contractor "decontaminating tank": Tank Decontamination Contractor: Address: City:_ Zlp:_- Phone N: Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an approved manner as required by Cal EPA. Name: Title: Signature: Date • ♦ +a++» « +• +++• a+++ •af4•r♦r}» + + 4 ♦ ♦aa#f ►aaf ♦Arlt+} S ,C" UN - 'o a signed anda e157 an suf ror ze represenfa re o t e treatment, sto age, or disposal FacIffif accepting tank and/or piping. Facllhy Name: Ame; iclear., Inc. Address: 2570 Almond Dr. City:Silver Springs, j��V 89429 Phone N: 800 ) 471-2105 at Date Tank Received: Name: Title: Signature: Date ««««««4}«««•+•#4♦}:ar+#+}•/4}+a+++a••}+♦a•r+}}+«+}•••1».»»+»r+4+++4a#♦#.♦r#rrrrrara+laaararrrrAaflrlrr�►r . E11 23 046 (Revised 9/11/96) Page 10 I )