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$A� JC]A$IN LOCAL H AL.-r1*DISZI2I= <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <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 by disposal or <br /> recycling facility. The holder of the permit with number noted below 1s responsible for <br /> ensuring that this form is completed and returned <br /> FACILITY NAME: Spear Manufacturing <br /> FACILITY ADDRESS: 4350 N. Newton Road, Stockton, CA <br /> TANK ID 039- - 1-1 ,000 gal. unleaded gas tank EPA#: CAD 981457971 <br /> *R!!!!R#*R#R*#**!!!!!!!*!#!t!t###!!t!t#t*!!*##*!**!!!lRRR###*##tk#*!t##tlttR!!t!!#!t!##t!!! <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 95240 <br /> Phone#: ((.2 368-6175 <br /> Telephone: ( ) Date Tank Removed: <br /> *R##*#t*#lRRk!*********t#R**#**t!****#***t*R!#R#*R#*R*R*#####R#*#R*RRt**R!**!!!!!R!!!t!!!## <br /> SECTION 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: 95240 <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 /> !*!!Rt!***R**R###!###*#RtRRtR#tR*R*R!#!RR#t*#RR#*#R#RRtRR#**R**#*#R*#*R#*#*#*#t#!!**!***!*t <br /> SECTION 4 - To be filled out and signed by an authorized representative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SICSIATURE AND TITLE <br /> !#**R!#!R!t**#tRtR#t!!#***R*!#*##*####R#***t*R!!!!!R!!R#RRt*R!!RR!###*R###*!###*t!!R!!!!R!R <br /> EH 23 049 11/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />