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SMV .?OIw=N ilc)c* I., 141aALT0I?I SZ'RI cIrr <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <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. Tbc holder gf the permiL with numtaj nQted belgy is res2gnsible for <br /> ensuring that this form is completed and returned. <br /> FACILITY NAME: Vacant (Old Butcher Shop) Bank of Stockton <br /> FACILITY ADDRESS: 1210E Victor Road, Lodi , CA EPA Site # CAC 000146781 <br /> TANK ID #39- <br /> SECTION <br /> 39-SECTION - 2 - To be filled out by tank removal contractor: <br /> Tank Removal Contractor: JIM THORPE OIL INC. <br /> Address: 351 N krtan Road Lodi CA Zip: 95240 <br /> P 0 Box 357_. Lodi . CA 95241-0357 �Pihoone#: (209) 462-4581 <br /> Telephone: ( ) Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: ` �-✓l ^��c ��� - /�L �' <br /> Address: j 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 /> 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 SCHNITZER STEEL PRODUCT:) CL. <br /> MOO FOtse)IM B- Li. <br /> RANCHO CORDOVA, CA 95742 <br /> Address: 916-985-4810 Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> ****************s*s*s*ss*sssss*ssss*sssssssss*ss**s*ssssss*sss*s*****ssss*******ss**s****** <br /> EH 23 049 22/88 <br /> MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. AFFIX PROPER POSTAGE. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. 0. BOX 2009 <br /> STOCKTON, CA 95202 <br />