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. .�^' • SAN J'O�I N L002�►I� H�--A T.T� DISTRICT <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> `xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*****xxxxxxxxxx****x*xxxxxxxxxxxxxxxxxxx*************xxxx** <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 /> ensuring that this form is completed and returned <br /> FACILITY NAME: Vacant (Old Butcher Shop) Bank of Stockton <br /> FACILITY ADDRESS: 1210 E. Victor Road, Lodi , CA EPA Site # CAC 000146781 <br /> TANK ID #39- <br /> xxxxxxxxxxx**,txxxxxx*xxxxxxxxxxxx�xxxxxxxxxx*�*xxxxxxxxxx*xxxx***,txx*x**x**xxxxxxxxx*xxxxx* <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 odi CA Zip: 95240 <br /> _ P. 0. Box .357 Lodi . .A 95241-0357 Phone#: _(209) 462-4581 <br /> Telephone: ( ) Date Tank Removed: <br /> xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxx <br /> SECTION 3 -To be filled out by contrac or "dcontaminating tank": <br /> Tank Decontamination" Contractor: <br /> Address: Zip: <br /> Phone#: <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 /> *x**************************x***x**xxxxxxxxxxx********x**x**xx*xxxxxxxxxxxxxxxxxxxxxxxxxxxx <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 /> *****x*xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx,�*xxxxxxxxxxxxxxxxxxxxxxxxx*xxxxxxxxxxxxxxxxx <br /> EH 23 049 12188 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATM: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTO N, CA 95202 <br />