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FROM :JIM THORPE OIL FAX NO. :1 209 368 1851 t. 12 2004 06:10PM P4 <br />SANT JOAQUIN COUNTY <br />VWMONMENTAL BIALTR DEPA 1-T:11 ENT <br />L'YDEItGROUND 51 bRAGE TANK DLSPOSITION TRACKING RECORD <br />##Yk*###aYx**IFIR*W�F�##i�*IF**i#fM**ix�Clklk kft�*#'#MiWiYrl�*#*1f lFiklk#�*#*ti�x##*#*#*#x*9i##*###ikitw#*Ikik*Ysi.*�1#1�ilk*�'IeiR#t*• <br />SECTION 1- S7C Environ tal Health Deparn'ne tIs Tank ?racking Sheet shall accompany each taz+kta�h d withit sof <br />,amf,$ication number. ?,bc Tank Tracking Sheet is to be retu=ed m the'Ezlvironmental health Depart! that this form is completed <br />fac - The permit holder is respo=-ble for �staing omP <br />�ccptance a#'the tank by the disposa3 or rscycliag ""a <br />rC$trn61 <br />FAcnM NAN E: <br />FAcniTy ADDRESS: ' <br />PREVIOUS TANK CONTENTS- <br />TANK ID #39 - TANK SIS' .., <br />SECTION 2 - To bt fined Out l}y Wk removal con"etor. 4 <br />-rWk Removal contractor. <br />zip <br />Address _...r� <br />Phone #: Date Tank R=oved - <br />SECTION 3 - To be filled out by contrictur "decontaminating " <br />Tank Dcconmmination Coatracwr <br />��w <br />Address:_l.�7 1� . <br />Phone #: ,� <br />tbrou sigmmrc below ftt the tattle has <br />Authorized representative of contractor certifyia$ Sh <br />mama as required by cal. EPA, <br />� <br />Name; <br />I #.*'P " <br />s.a�xxrr�xrsr�***.+te' <br />r.ynht*sw�*ss�wrx#*�a ar rrrw �w*x* rxw"kr#+ * =rage, or d�pS81 f8CZ7.tj` <br />SECTION 4 - To be signed and dated by an authorized represeIItzitive of tht =rage, <br />=eptiug tank =&or pipms- .-...-'e' <br />in as approved <br />❑r <br />l dZ_Pac1iyN==. tCi <br />Phone #: <br />Dane Tank geceived: �' <br />Name: Titla', <br />Page 10 <br />EH 23 046 (Re <br />visad 3115102) <br />�L <br />