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Jim Thorpe Inc <br />Apt. E. 2014 813AM Re*ic Services <br />209-462-9861 p.1 <br />L I V 8 D <br />3 20'4 ,L7 <br />ENVIRONMENTAL HEALTH DEPARMEN-AL <br />SAN JOAQUIN COUNTY HEALTHY _ `'�rrENT <br />Telephone; (209)468.3420 Fax: (209) 468-3433 /l� <br />UNDERGROUND STORAGE TANK DISPOSITION TRACKING RECORD <br />'\N\ui\Mw1\NNnIN..uNu\NIu\NM.\.\-1N.....1.\N, NtHNIf\Mil\IN\MN\\NMIy\\NN\m11. <br />SECTION 1 - SJC Environmental fieallh OepaPmenra Tank Tracking Sheet shag accompany each tank affixed with its site <br />idoniffieMlon somber. The Tank Tracking Shout is to be returned to the D*Onmentsl Health Deparenent g4thln 30 oll or <br />acceptance of ft lank by the disposal or recyding Mcnity• The permlt holder is respons�le <br />and returned, (or ensurktg Thai this fomt is completed <br />FACILITYADDRE55'_ /�`- �3 ii�7f /0j <br />TANK ID#39.,H • r ANKSDE: Jo/NCr <br />p9EVi0USTAMKCONTEhf'f• r� <br />aYaleY#! i1rYYiaYYYYiawikYfrirMJwAwiwk4lili#iwl,##!!y#fYe!###IYMMFRw IY,Y*#YrkuwyrikyYYwY;Cf YYMaINeYIM#fl±fa*awcYiY <br />SECTION 2 -To be filled out by t2nk ratnoval coninotor: <br />Tank Removal Conlrador. <br />Addross; 1 0 e).: 36r% ._City: <br />PlwnerrtZo9) y3GrYro/7S Date3erKRemoved r /.Z —/' <br />.##aaawYraam#ar.aalraa*trier.!'ear#Yaai.#,......ta++Ya#YY.YaaaawaataaYYa»eaarY+kaaaatiarrk,t ar�yraaa#Y+Y.Y# Ya <br />SECTION 3 -To he filled out by contra ctor"deeontaminadng tank": <br />Tan![ Decontaminaeon <br />Clry:_ t?l,? / zip: L t-1 <br />Phone <br />Aud+erized representativa pf contractor ceNfying through slgnattue below Ihat <br />manner es regrdred by Cal EPA. <br />Tlva:CA2jii AIC%& Slonal <br />Ya'tYYYYla#iaraaYYYYY <br />�SECTION 4 -To be efllned asd Baled by an aulhorized iopreaenlagve <br />!/9..J,KS Taecwptn9 [ask and/or ytPh,9, <br />In en approved <br />treatment, stcrage, or dlsponel faclky <br />Address: V.Z.2'%..atrS'•,, <br />� �r7� e2eetg <br />City crl/� Zip: <br />_ <br />Phone <br />�7 18C�CdgS5 /FJc' <br />R po ed: —l/ <br />`1 <br />mat / <br />tiJ -ct S /1Q <br />js /yy. <br />Tn'r <br />�-f Name /t7(pR <br />i a / <br />Tide: ,Qfi(il <br />Slgnatu Data/ <br />;�i %-ctL 1'i�rN<: moo; <br />SAH Ni T-Ze L,Vc TS <br />i <br />Ar�I)r2i`SS- <br />r,3> Jal��n%,r .� <br />� � uOp- r'dGS�//7 <br />�d%/�� �gS - L}'f!l rJ <br />Ra'RD i�J4nlGNo C.'drRr7orl� <br />C . r . , � —. - � • <br />9�'�5�z, <br />EU23 046 <br />4&VS71lt).12dAd #'�J7J%eCA rq-^�J�tj6 <br />'14.46-4 (z.O rf) <br />• i •� r nnc_vnw_cn> nm tea ini i � n nr <br />