Laserfiche WebLink
BJILN .TCkAQ SN r: C>C''n i-TEAL"rH _ aI B7Tt1 arr <br />R11Rm!lRftllRRlt#Rtttt!!!!Rt#ttt#ttRlRtttRtttRRlRlRRRRRttRtRtttRtRRRlRRlt#RRRt!!4R#4tltRl til <br />RRCIICN 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 by disposal or <br />recycling facility. Me holder of the permit with number noted below is r"nnnnl hln Fnr <br />FACILITY NAME: Best Cleaners <br />FACILITY ADDRESS: 541 N. Hutchins, Lodi, CA 95240 <br />TANK ID 139 - EPA Site # CAC 0002.02573 <br />Rf RRtttttttt#t#tttlttlRR!!!#R#Rt#ttRttR#fi tt#tt##Rtt#tRRxxx#txRRR**tl4tRRR*#RtRt!!!tR#!RtlR <br />BW TION - 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 '5240 <br />_'(_2(7- ,63-6115 <br />Telephone: 1 ) Date Tank Removed: <br />RRR!!tRltltttxtt*xtttttttRlt#tt#ttRx!!Rx#tRR#!*x#tR*Rt#Rt##t!R##RRRRtttltRRRR*#t!t#tRtRtRRt <br />OWTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor -Cal Oil, Hauler of rinsate <br />Address: 351 N. Beckman Road, Lodi, CA Zip: _g524O <br />Phone#: (209) 368-6175 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />—_ Vice -President <br />SIGNATURE AND TITLE <br />RRtttRRltRt**lRtRRRRt#tt#Rt*Rtlt#ttxRRR!*Rt*RxRR#ttt**xRRxRRx***#RR***#ttx******xRxx***RR#t <br />SRCTION 4 - To be filled out and signet] by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility <br />Address: <br />#: <br />Date Tank Received: <br />!p: <br />AUTHORIZED SIGNATURE AND TITLE <br />RRlRRlt#RtRlttRRtRttt#ttRttttlRttlR#xlRRt###x#RiRtfltt#tR#ttx#t#!R#ttRRtRRRtt#tttRttttttttR <br />IN 23 049 12/88 <br />11AILINO INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br />SAN JOAOUIN LOCAL HEALTH DISTRICT <br />ATTN: UNDERGi20UND TANK PROGRAM <br />P. 0. BOX 2009 <br />STOCKTON, CA 95202 <br />