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UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />SECTION t - Public Health Services Tracking Sheet will accompany each tank affixed with its site Identification number. <br />The Tracking Sheet Is to be returned to Public Health Services within 30 days of acceptance of the tank by the A14sal or <br />recycling facility. The permit holder is responsible for ensuring that this form Is completed and returned. <br />FACILITY NAME: Jefferson School District EPA Site #CAC 001001248 <br />FACILITY ADDRESS: <br />inne Road Tracy, CA <br />TANK ID #39 - L&Zc%-L&/Tank Description: 500 Gallon Diesel/ Gasoline/ Waste Oil <br />SECTION 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: Jinn Thorpe Oil, Inc DBA Rich -Mart Construction <br />Address: <br />351 N. Beckman Rd./ P.O. <br />Box 357 City: <br />Lodi, CA Zip: 95241-0357 <br />Phone #:20`( <br />9 ) 462-458 1 <br />Date Tank Removed: <br />/"Z "V 19-3 <br />SECTION 3 - To be filled out by contractor "decontaminating tank": <br />Tank Decontamination Contractor: Jim 'Thorpe Oil,DBA Rich -Mart Construction <br />Address: 351 N. Beclanau Rd./ P.O. Box 357 City: Lodi, CA - Zip: 95241-0357 <br />Phone #: ( 209) 462-458 <br />Authorized representative of contractor certifying through signature below that the tank has been decontaminated in an <br />approved manner as required by Cal EPA <br />Signature: <br />Title: �/ <br />••r•••••u••••r••r•u••••••••••r••u••••••••••r•r••••••••••••u••••u•u•r•♦••••r•••u u•••••r••••rr•••r••• <br />SECTION 4 - To be lsiigned and dd�ated by an authorized representative of the treatment, storage, or disposal facility <br />rank is free �itf %j s�udgegiparA hydrocarbon vapors upon delivery to Schnitzer Steel. <br />Facility Name:_ <br />Address: <br />Phone #: ( 916 <br />Date Tank Recei <br />Signature:_ <br />Schnitzer Steel Products <br />12000 Folsom Blvd. <br />985-4810 <br />ER 23 049 (Revised 7-10-92) Page 10 <br />City: Rancho Cordova Zip: 95742 <br />Title:��/�/� <br />