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FROM :JIM THORPE OIL FAX NO. :1 209 368 1851 r. 13 2005 11:27AM P2 <br /> SAN JOAQULN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br /> wwipwwYuw.R.MYW Wrr.Y#Yr#ruulumru.F.rrruu.urwc..r.li..rrrr»FUWmrrw.w.wwW W r!YY#Yuwwrrrrwi.w### <br /> SECTION 1- Public Health Services Enviroamental Health Division Tank Tracking Sheet shall accOmpsay each tank hued with <br /> irs site ideauficanon number. The Tank Tracking Sheet is to be returned to Public Health Services Environmental Healdt Division <br /> withi4 30 days of arteptancc of the tank tn- the disposal Or recycling `aciliry. Tec permit holder is tctiponsible for ensuing that <br /> this form is completed and reeu=cd- <br /> FACILITY NAME: <br /> FACILITY ADDRESS: <br /> TANK ID g39 - D/ 300.5 TANK SIZE: DO PREVIOUS TANK CONTENTS:,// <br /> .�q�sw»twin.+w.w+v..+rw#rrrram«�s##�.+�+#r#rrrwww»srr�rr###rrmrwrr.mmowsrnr . <br /> SECTION:-To be filled out by tank removal contractor. <br /> Tank Removal Contractor. <br /> Addtras: �3 7 ,�. 2/l. city:_ C oy Zra: <br /> Phi rY: 4�7 Date Tank Removed: 211 q 10 <br /> #coy#+y�www#r#www+rurrs.w..wr#sswsw r+om»rr#sM.rrr#r#rr.www.w##o+.rr#rrwrn#wwwYYr#..Y+�#r�'�'� <br /> SECTION 3-To be filled out by contractor"decontaminating tank": <br /> Tank Decontamination Contractor: //"1 -_y��7`G'/�f" �- O/C ���• <br /> Address:, 7 S— L��G/�i��� City: 1�2� Zip: 2a-2- <br /> Phone#: Lac <br /> 1J ` �- 5W- <br /> Authorized mpresemative of connector CVfYm& through signature below that the tank h4 bees decontaminated in an afmved <br /> manner as requiireddbby Cal EPA. �/ <br /> Name: /`//ill i�0 Title: ���:��/Ft✓/ Signature: Dau oZ d SJ <br /> - r+.FrWVYYO»W+YuwXY.uwvl�i.Aa-aW#+a<YY:ltlrw."�' <br /> SECTION 4-To be signed and dam by an authorized representative of CM. storage,or disposal facility <br /> acccpm*tank and/or piping. <br /> Facility Name: �7 /esl-� �/lj(� ���G <br /> Atidttss: 3��3_� S/�s •-- _ ctty:�0/.�l�C' ziQ: `�,6Dr 1 .� <br /> Phone� (moo) a- �f S/73�63 - <br /> Dam Tank Received: -J <br /> S. $`� Date DA" <br /> Name: -/7✓/�"'t Tidec_�,�� <br /> rmw W.w..rwW+.row+wrr Wwuwraawa##mWr.sw...coin#r..�..wrwrrt.wwr##wrrrmrw+..wrwwr..r.wmww+.�'r <br /> EH 23 046 (Revised 10/19/98) Pap 10 <br />