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SAN JqWLiIN L.00AL.. M= r* DISTRICT <br /> UNDERGROLM TANK DISPOSITION TRACKING RECORD <br /> tfftRRtf RttltRRt**RltRlRRR*R***tRRlRXRlRXXXtRRRRRRtRRRRRRRRtRRRRRRtRRXRtRtt*RRRt*t!t*Rttttt <br /> SA)CTION 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 tbe permlt_wit:h number noted beloy Is responsible for <br /> awurina that this form is completed and returned. <br /> FACILITY NAME: Ripon Fire Dept. <br /> FACILITY ADDRESS: 142 S. Stockton Ave. , Ripon, CA 95366 <br /> f I <br /> TAID 139- r - <br /> NK 1 - 550 gal . UL gasoline Tank EPA #CAC 000280913 <br /> RRtRRRRRRR**R***!*XRX*RXRRXX***RRRRlXRR*RRRXXXRRRRRRRRRRRRtR*XXR***RRlRRRRRRRtRlRRtRRRf lXRR <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 A: -368-6175 <br /> Telephone: ( ) Date Tank Removed: <br /> f RlRRXRRRlRRXR*RRRR**f*R*RRRR*XXRR**X*R*R***RXR*RXR*XR*RR!**RRf RRRRR*RRXRtRtXtt*lRtRRtftt!! <br /> SZCTION 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$: (209 368-6175 <br /> Authorized representative of contractor certifies by signing below that the tank has been <br /> decontaminated in an approved manner as may be regulated by Department of Health Services. <br /> Vice-President <br /> SIGNATURE AND TITLE <br /> RRRRRRtR*R!***RRR*!X*RXXRRRXRRRRRRXRRRRRRXXR*RRRR*XRX*XRRRRRRRR*XRR**R*RXRXXRRXXRRR***R*R*X <br /> SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Name Scl,,,iu� <br /> Address: i, vJD i=c 'i so. /_�/u�� Zip: <br /> ip Phone$: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> RRRRIRXRRRRX*RXR**RtRRRRRRRXRXXXXlt*RR*RRRRXRRXRRRt*lRXXR*RXRX*RtRX*RRRRRXXlRRR*RR!!XlRRlRt <br /> RH 23 019 12181 <br /> MAILING INSTRLICTIOLIS: FOGA IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />