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rwhSAN 70AC10IN LOCAL tM T•THVISZ'FZI= <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> ECTION 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed witits 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 is resR=ible for <br /> .nsuriog that this form is completed and returned. <br /> FACILITY NAME: Herbert Ostermann <br /> FACILITY ADDRESS: 705 N. School Street, Lodi , CA 95240 EPA Site # CAC 000168269 <br /> TANK ID 139- a' � - N <br /> *RRltR!***xlxxxftlRR!!x!!RR#xx!!!!**R**RRRRxR*xx#x*Rt!*xRR**!*RR***tRRRtRRRRRxRRR**tRRRltlR <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 yip; 95240 <br /> Phone#: <br /> Telephone: ( 209 1 368-6175, 462-4581 Date Tank Removed: <br /> RRRR*!R*RRlt*xxxlx*Rx**R**t*x*t*RtR#RxR*RRtRlRtRR*R#**!***RttttRRttltt*RRRttRlR#!!!*R*tRtRR <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: Jim Thorpe Oil , Inc./ Nor-Cal Hauler of Rinsate —/leco/®t- <br /> k r"racf,ep <br /> Address: 807 E. Black Diamond, Lodi , CA Zip; 95240 <br /> Phone#: (7ng) 462-4581 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontami in/4n appz nner as may be regulated by Department of health Services. <br /> SIGNATUE AND TITLE <br /> t !!*t x*xx****xR*RR!!RlRR *tx!*R**tRxRlxx*xRRRx*!#x!R**!!***RRRRRRRRRlRRRlxxlxxlR#*RtxRx <br /> SECTI 4 - To be filled t and signed by an authorized represnetative of the treatment, <br /> Stora , or disposal facility accepting tank. <br /> Facility Namecrs <br /> SCHN7,Ltn-S 0C§ <br /> 'i2000 FOLO,A BLV A ' 5742 <br /> Address: ppNf Ho Cr-RD J '» ' Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIONATU E WVITLE <br /> RRRR###xRlxx*x*x*xx!*!Rt*!R!*xR**tttt*!*!R*R!*RRRRRt* R tRR*RRRRlttttRRRRRRRRRx!lRtRRRlRttt <br /> RN 23 049 12/88 <br /> NAILING INSTRUCTIONS: PCI# IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />