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r <br /> SAN .702%.QLJ I N T OC.AI+ HEAT.'1'I I D I S'TIZ I G"`I' <br /> UNDERGROUND TANK DISPOSITION TRACKING REOORD <br /> ing <br /> ll <br /> ny <br /> ch <br /> affffixed with itsSsiteoidentificationquin Local anthber. ThesTrack`ing Sheettisito be rreturnedato Sank <br /> Joaquin Local Health District within 30 days of acceptance of the tank by disposal or <br /> recycling facility. The holder of the permly- mgr noted below i respgnsible for <br /> ensuring tht reit form is comole'ed and returned• <br /> FACILITY NAME: California Water Service Com an <br /> FACILITY ADDRESS: corner of P1 mouth St. and River Drive Stockton CA <br /> TANK ID 139- G)0 - EPA Site # CAC 000191133 <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: Jim Thorpe Oil Inc. <br /> 351 N. Beckman Road, Lodi , CA Zip: 95240 <br /> Address: <br /> Phoned: .1,209 462-4581 <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc./ Nor-Cal Hauler of rinsate <br /> Address: <br /> 807 E. Black Diamond, Lodi , CA Zip: 95240 <br /> Phone#: (209) 462-4581 <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 /> SIGNATURE AND TITLE <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received. <br /> AUTHORIZED SIGNATURE AND TITLE <br /> SH 23 049 12/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAbi,r:. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTGN, CA 95202 <br />