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69/13/2007 13:55 1-209-368-1851 JIM THORPE OIL INC . <br />08/20/2007 MON 12!27 PAX 20t 3633 SIC EHO -I- Jim Thorpe Oil <br />IWO, t'AGc 11 <br />ENVIRONMENTAL-REALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209)46&3420 Bax: (209) 468-3433 <br />UNDERGROUND STORAGE TANK DISPOSMON TRACPUNG RECORD <br />. nx.ray.rxrru...... **.YYYt.........YYYY.1.1.......... YWwu......H.VNY r.YWw......... «.y WY...r ry..a..r r <br />SECTIOY 1 -SIC @nno Tank Re itt,i"s Oaipar`maht'a Tank Tricking Sheet [hell wcompeny tncb tack affixed with is site <br />identification she W The Teak dispoTmcsal <br />»g Sheet is to he retumed to the Environmental Health D <br />romplYtod sad the <br />mtumed Ey the disposal Or ttcyeligq Ijgtlun,- T parmi! holder it responaibic r mat>rrin wt 311 lour of <br />gdmt this form is <br />FACII-ITYNAME: %�_ T -T Lr�fJ�'J�,.a_ , r/%. _ t .• <br />PAGE 02/05 <br />®011/013 <br />FACILTTYADDRESS: <br />TAWK1D A39"�� JL /� 'lL� I .� • 5 / l\ / �j <br />TAMC S12E: r��pREViOUS TANK C <br />Oh7iNl5' <br />sVre..Ir...... Mrr4... YrYYryLY11Y... YY ... r.... YWYYYYYY.MY.LLYY......xrYYYYYYYNYYYY........r <br />SECTION E - To be filled Dor by tack removal coatnctnn. •`......rs YyY sa. <br />Tank Removal <br />Phove tll 20 Ditto Tank / <br />Removed: 2 Q <br />Lrv.................. Or..rr.uu.urY........ <br />r '-��• <br />Y..IY.yi Vrµr... I...............rr.YlrrxYYYxVYY rYY.YYYYY.[r....YY...Y.1Y <br />SECTION 3. To be Pfl� out by contractor "derontainibatinn rya Y�•. <br />Phone d; <br />Authorised rtprea ni tiv¢ of contractor camifyleg thr000 6LrA("re haloes thatrile tank <br />mnnreras regnimd by ql EPA. <br />•s sr Lx YYxu YYL YrrLrp..........WWxVx Wr4...o...Mb uu......... <br />SECTON d- To be signed and dazed by an avlhor6Ta0nt <br />woptin lack en/d/or p(pinL• P aotortva off <br />rtdlty Name, 2/,Lz <br />Phone e;( ! <br />pate Tank Recehra . 9�/ 0 /0 <br />u ncamm od in an approved <br />Date Z f A% <br />WYYr Yy...... 4............ <br />or disposal facith), <br />ZIP: <br />------- - <br />r LYVYL ItLY1YYYYYYWYrLYYYWLYYYf11YW LtfYVYILLYWYV(Wr.YMYrYYY1YYLYL.LfLL\............i.........#*.xYYYYY..... <br />BH 23 (W (Revised sN/06) <br />10 <br />