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SAN aOAQui i-4 r ocCA. HH:A 9PH ISI STF2I CT <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. The holder of the permit with pumber noted below is responsible for <br /> ensur.ing that this form is completed and returned. <br /> f <br /> FACILITY NAME: <br /> FACILITY ADDRESS: 7 ✓ �� Manteca, CA <br /> EPA Site # CAC 000151965 <br /> TANK ID #39- <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 Zip: 95240 <br /> P 0 Box 357 Lodi CA 95241-0357 _ P�h�one#: (209) 462_-4561 <br /> Telephone: ( ). Date Tank Removed: <br /> SECTION 3 -To be filled out by contractor "decontaminating tank": <br /> Tank Decontamination" Contractor: JIM THORPE OIL, INC:_____ <br /> Address: 807 E. Black Diamond Way, Lodi , CA Zip- 95240 <br /> Phone#: (207T-6£-7+77 <br /> Authorized repres tative of contractor certifies by signing below that the tank has been <br /> decontaminated i ved mann as may be regulated_by Department of Health Services. <br /> SIGNATURE AND TITLE <br /> SECTIO �4 -jTbe filled out and/signed by an authorized represnetative of the treatment, <br /> storage, orposal facility accepting tank. <br /> Fac i 1 i ty Name _.ti <br /> Address: -A�.` <br /> Phone#: <br /> Date Tank Received: <br /> AUTHORIZED SIGNATURE AND TITLE <br /> EH 23 099 12/88 <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 />