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SAN .10A( TIN LOCAL 14 A rrF DI STRI 4=r <br />sss�:itirititit�*s:ssss���*�***ss�***�****sitssa�*ssirssitsirssirsssirss�*suss*sss*sirs****ir,etirssiritsit*>t <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 number noted below is regggnsible for <br />ensuring that this form is completed and returned. <br />FACILITY NAME: Lodi Ready Mix <br />FACILITY ADDRESS: 851 E. Lodi Avenue, Lodi, CA 95240 EPA Site # CAC 000158517 <br />TANK ID 839- - <br />*ssssssssssss�***sieirirsssssss�*itirsir>tsssssssssirssssrtititititssssirssir�*�***itirsss***sssie**sitirsirssirs <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 9 Phone#: (209) 462-4581 <br />Telephone: ( ) Date Tank Removed: <br />SECTION 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#: X209 462-4581 <br />Authorized representative of contractor certifies by signing below that the tank has been <br />decontaminated in an approved manner as may be regulated by Department of Health Services. <br />SIGNATURE AND TITLE <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 <br />Address: <br />Zip: <br />Phone#: <br />Date Tank Received: <br />AUTHORIZED SIGNATURE AND TITLE <br />sssssssirssssssssssssssssssssssssssssssir*sssssssirsscrit*ssit�eitsssirsssssssssiritssssssssssssssssit it <br />SH 23 049 12/88 <br />HAILING 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 />