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t"MM WJND TANK DISPOSITION TRACKINC3 L wo= <br /> S1WTI0N 1 - The San Joaquin Local Health District's Tracking Sheet will accompany each tank <br /> affixed vith its site identification number. The Tracking Sheet is to be returned to San <br /> Joaquin Local Health District within 30 days of aeceptame of the tank by disposal or <br /> recycling facility. <br /> FACILITY NAME: Lodi Ready Mix <br /> FACILITY ]ADDRESS: 851 E. Lodi Avenue, Lodi , CA 95240 EPA Site # CAC 000158517 <br /> TANK rD 139- - <br /> sssit*ssssfrirsssssssss**iissssirsssssiessssssssssssssssftsssssssssssssssssftssssssssssfrssssfrssftsss <br /> M=ION - 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 , C Phone/: , (209) 462-458 <br /> Telephone: ( } Date Tank Removed: <br /> ir*frsssssssssfrs*s�*����***����irsirssssitsssssssssfruit*fts�*irssssssssirssftsssfrsiesss*�sfr**���sss*sit <br /> SECTION 3 -Tb 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#: 277 462-4581 <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 /> sits***ssssssssssss*ssirsitsitssirirfricsssssssirsss*ssssssftss*sssiters**"*sss*sssititss>tirssssssiriritit*iters <br /> 99=10N 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storage, or disposal facility accepting tank. <br /> Facility Nance <br /> Address: Zip: <br /> Phone#: <br /> Date Tank Received: <br /> AITITHORIZED SIGNATURE AND TITLE <br /> ssssirs����*sus*s*��*irftssir�*siess�>t*�ssssfr***�**��*��sftfrs***ssssiter*ssssssssssssssssssssssss:� <br /> SH 23 049 I2/88 <br /> WAILING INSTRUCPIONS: FCW IN HALF AND STAPLE. AFFIX PROpFR POSTAGE. <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> ATTN: UNDERGROUND TANK PROGRAM <br /> P. O. BOX 2009 <br /> STOC KTCN, CA 95202 <br />