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SAN JOAQUIN COUNTY PUIILIC IIEALTII SERVICW <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> «arra•••#}«4a«««war!}44►#a«f#!###}a«#a4«f+#afar•#•#f#afra##f►►ffla►►►444#►4►►►►►►4►►4►►N►►►►►►►+►►44►4►►► <br /> SEcTI(/N 1 - Public Health Services Environmental llealth Division Tank Tracking Sheet shall accompany each lank affixed <br /> will, Its site Identification number. The Tank Tracking Sheet is to be returned to Public llealth Services Environments! Health <br /> Division within 30 dans of acceptance of the tank by the disposal or recycling facility. The permit holder Is responsible for <br /> ensuring that this form is completed and returned, <br /> rnclurY NAME: <br /> Hutchins Street Square E.P.A. q CAC 001239520 <br /> 121 S. Hutchins Street, Lodi. CA 95240 <br /> FACILIrY ADDRESS: <br /> TANK IU 6,000 gal lo N39 - TANK SIZE: $Ts1EV10US TANK CONTENTS: li4 bunker o11 <br /> Isar♦Mara+a«aa4}««ar#♦#waw4faa##4+afa}•fair•fa#+!!a}a#+##4!!#fww44ff4f44f44l44►►►►►4►M►4►f4►►►►f►►►►► <br /> SF,C'1TON 2 - ho be filled out by tank retnoval contractor: <br /> tank Removal Contractor: Jim Thorpe 011 Inc. <br /> Address: 351 N Beckman Rd./P.O. Box 357 City: Lodi, CA Zip: 95241-0351 <br /> Phone N: ( 2_009) 368-6175 Date Tank Removed: <br /> araaaraf aar#a#4t«fwa#«!w4#!}+aaf++aa♦+#fl44wara+alrrawf+#wiwall44#f4►4444w4►►4}wlw w4a##+##!af#f 14 <br /> SECTION 3 - To be filled out by contractor "deconlaminnting tank": <br /> Tank Decontamination Contractor: <br /> Address: City:_ Zlp:__ <br /> Phone I: <br /> Amltorized 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: Title: Signature: Dale <br /> ♦ r . as r arra+a • rr •raa•r aa+•rwaaat#rr r # a! r as + a ar#a#+ lfaf 44#►### <br /> o e 3Tgned and dated by an authorized represent• re of the realment, sto age, or d1sposaFfacility <br /> accepting tank and/or piping. <br /> Americlean, Inc. <br /> Facility Name: <br /> Address: 2570 Almond Dr. , Lily.Silver Springs, ijy, 89429 <br /> Phone IF: 800 ) -471-2105 P <br /> Dale Tank Received: <br /> Name: Title: Signature: Data <br /> radar ra#aar}aalaw+•war«+r+arrwwra#wr++wirr#+arra#ww+i++++a+#asa#affwwff4f4►►}f444►44►►4►►1►4#►► <br /> Ell 23 040 (Revised 9/11/96) Page 10 <br /> 1 <br /> J <br />