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SAN .7 OA JI tJ ICC. . <br />Cl_.i�:►:.e- T=;7�=T:i�it�! i�S��•'�3�i� �f"a��:iT:ii::c7�T���_; � <br />xxxttxxtttxxxfrfetxxtttxxtttftxxxxxxtxxxxxxxxxxttxxxtxxxtxxxxxxxtttxttxxxttxftttfttttfet:xttttttir <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. Mx holder of the permit wig number noted below is responsible for <br />ensuring that this form is cgWleted and return_ <br />FACILITY NAME: Lodi Readv Mix <br />FACILITY ADDRESS: X51 E. Lodi Avenue, Lodi, CA 95240 EPA Site # CAC 000158517 <br />TANK rD 139- I3 S -Q, <br />x�txxltxxxxxxxxxxxxxxftxx�Rxitxxxxxxxxxxxxx*xx*xx+rxitxxrt*xitsxs�t xxxxx�tx*x*xftxxxxxftxxxxxx*tuft*xxxR <br />SECTION - 2 - To be filled out by tank removal contractor: <br />Tank Removal Contractor: JIM THORPE OIL, INC. <br />Address: <br />x <br />oad, Lodi, CA <br />_Zip: 95240 <br />N: (209) 462-458 <br />Telephone: ( ) Date Tank Removed : <br />tatttxfttttttxxxftxf: xxtxxtttttxxxftxxxxttxxxxtxtttxttttxxxxttxtttttttfttftftfettttttttttxttttttttt <br />SWTION 3 -To be filled out by contractor "decontaminating tank": <br />Tank Decontamination" Contractor: JIM THORPE OIL, INC. / Nor Cal Oil hauler of rinsate <br />Address: 807 E. Black Diamond Lodi, CA Zip: 95240 <br />Phone#: (27 462-4581 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved wanner as may be regulated by Department of Health Services. <br />'-Z'816NATLIRF AND TITLE <br />xttxxfrxxfrxxxftxxxftx*xx*****x******xtxtxtxfrfrxxxxxxftxxxxxxxxxxxxxftxxxxxxxxxfrxxxxxxxxxxxxxxxxxx <br />SECTION 4 - To be filled out and signed by an authorized represnetative of the treatment, <br />storage, or disposal facility accepting tank. <br />Facility Name ;;;:;r:-- ^- - <br />RANCHO CC: <br />Address: <br />Zip: <br />-_ -_ -- Phone # : <br />Date Tank Received: <br />AmiokfzED SI ATC <br />*tttxxxttxxxfrxxftffftxxxxftxttttxxxtfttxftxxfefrxxxxxxxf� <br />RH 23 049 12/88 <br />MAILING INSTRUCTIONS: FOLD IN HALF AND STAPLE. <br />AND TITLE <br />tttttttftxftxxtttxxxxxtttttttxxttxxtxxxtxtt <br />AFFIX PROPER POSTAGE. <br />SAN JOAQUIN FOCAL HEALTH DISTRICT <br />ATTN: UNDERGROUND TAW PROGRAM <br />P. O. BOX 2009 <br />STOCKTON, CA 95202 <br />