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SAN JOIN LOCAL HAAT•TDI STRI CT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> *Y*tt*Y**xY*t**x**x*t***YYY*Y*x*YY**YYYYY*kYk*xYYYYYYkY*Yxk*Yk*YYx******x*Y******t*****fY*t <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 is responsible for <br /> ensurina that this form is completed and returned. <br /> FACILITY NAME: NOR-MAC, INC. <br /> FACILITY ADDRESS: 6215 Tam O'Shanter, Stockton , CA <br /> TANK ID 139-1aj k- - /00U 7" / EPA Site # CAC 000180845 <br /> *Y*Y**Y*Y*YY****Y*Yxx**xkY****x**x* Y******YYYx***xY*xxx***kx**RYYY******Y***txx*x*x**xYxx* <br /> SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL, INC. <br /> 351 N. Beckman Road <br /> Address: P. 0 Box 357 Lodi CA Zip: 95241 -0357 <br /> Phone#: (209) 368-6175 <br /> Telephone: ( ) Date Tank Removed: <br /> xxxxxxxxxxxx**Y**x**x**x**k***x*xx*kx*Y**x*Y**kk*xxxkxxk**x******xxx*xxxxxx**xxxx**x***xx*x <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL / Nor-Cal , Hauler of Rinsate <br /> Address: 807 E. Black Diamond , Lodi , CA Z1 95240 <br /> Phone#: p(20_97_37- <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 /> YYxYY*YYx****Y**YYYxxk***kkkx*x***x*x*YY**Y*Yx**x*****k*x*x*Yk***********k*kkk*xx**Y*YY**** <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 /> xxY***k**Y*Ykx***YxY*Y*Y*Yxx***YY*****x*xYxxx*x****xxxxxxxxY**xY*Yx***x*x*x*xxxY**x*Y*kxxxx <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOCKTON, CA 95202 <br />