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C] 'V I r4 r C cC- � OAr ,T I7 T S'I'EZ I G`T <br /> TANK DISPOSITION ULUX I NG REMRD <br /> SWrION 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 Pum <br /> FACILITY NAW:C• T. Brayton and Sons <br /> FACILITY ADDRESS.. 17 +5 Second St. Escalon, Calif. 95320 <br /> TANK ID 139- 1-550 gal . Diesel 'Tank <br /> sWrION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractors JIM THORPE OIL, INC. <br /> Address: 351 N. Beckman Road, Lodi , CA 95240 Zip: <br /> Phonelz (2u-9r) 368-6175 <br /> Telephone: ()_126861�5 Date Tank Removed: <br /> SWTI ON 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 zips 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 /> SWrION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Fac 111ty Name h4-ce <br /> Address: <br /> /. uV 0 u3�.d21p: 9SG 70 <br /> ��h a!v Ccn civ✓� Phone I <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> rH 23 049 12/88 <br /> NAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN.- UNDERWOUND TAMC PROM M <br /> P, o. sox 2009 <br /> sT cKTON, CA 95202 <br />