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SAN 170n IV3:N "CM .A.. HM AI.Irki r)x s'I'RY r r fY017116- <br /> UNDERGROUND TANX DISPOSITION IRAMING REOMD <br /> ZleoRRA*aNo*YRIRlR!*!A**RRRiRRRARRAa**A**RRRlAR*RRlRRR*R*RRRRNo*aa********RA*R**kDAN Ra*t <br /> 3h- .ON 1 - The San Joaquin Loral Health Diatrict'a Tracking Shaet will accompany each tank <br /> mffixed vith its site Identification nutasber, 4ttie Tracking Sheet is to be returned to Sart <br /> Joaquin Local Health District vithin 30 44,ys of acceptance of the tank by disposal or <br /> recycling facility. Tha holder of the aerra <br /> Aua{lixim thaL thin fom la =ylet fl d seL arned. <br /> Ii1CILITY NAM:_._ Lodi Ready Mix <br /> FAMLIW ADDRESS: 851 E. Lodi Avenue, Lodi, CA 95240 -- Ul A Site # CAC 0001ije511 <br /> ` TP-w rD 1139-- 61 f--/j ve) <br /> RtYRRlRR/RIRYYRY*Y*!*#RR#*lRRYR*BRAY*RR**Y**RRRRRRRARlRYv RRtlRY**RfARRYtYRRRRORl�S1lRR <br /> OPTION - 2 - To be filled out by tank removal contractor: <br /> Tank ftemaval Contractor: JIM THORPE OIL, INC. <br /> Wress: Beckman Road Lodi, CA zip: 95210 <br /> P, 0. Box 357, Lodi, CA 95241-0351Phone#: _. 209 462- <br /> Telephone: <br /> I ) Date Tank mo � °L <br /> titll4fRlt*RRRR*Y#Y#*RRRlRRRRYRR*#*YYRY*RY##RRR*RRRRRtYR*YRRRRM**RRtR*tt�r*RRRYYtYRRlY*Ri1AS!! <br /> 6HCar'IOM 3 -To be f i l led out by contractor "dee. ntamir.at ing tank": <br /> teak Decontamination" Contractor: JIM THORPE OIL, INC. 1 Nor Cal Oil liaulvi of rinsate <br /> 807 E, Black Diamond Lodi , CA 95-.110 <br /> Adr .ase: xlp: <br /> Phone!!: (?7FJT 462-4581 <br /> AUthoriaed representative of contractor crrtl'flea by signing belov that the tank has been <br /> kdiontaxinated in an approved wanner as may be regu3,ated by D"rtaent of Health Services. <br /> s ave -TI T M <br /> � +►R.kRRARf*RR**Y#RR!*RlRR*lRtR*RltYRRYARRRRYRRRR#RRaAAYRIRR***ARAB*RRYRRR*YRYYRRYRR#Y**YRYtY! <br /> FCH 4 - To be filled out and signed by an authorised represnetative of the treatment, <br /> I xt:orioge, or dinpwal facility acceptingtank. <br /> facility I{ase <br /> i addtaua: Zip: <br /> Phonef: <br /> 0!lto- Tank Received: /l <br /> t• , <br /> AMORIEW SICNA AND 'TITLE <br /> tt�RRRtRSRIY*!*****Re*!**R**YA*#*ARYAIRAt:**!R*R ! RRRA1rRAilR**YRRRY*RARIR*Ra2RY*R*s!Y**RRR <br /> t�StfU+ WMUMCN3. P'IZ IN HALF' AND STAPLE. MVIX PROPf14 Pi70'1AM <br /> SAN JOAQUIN LC+M HEALTH DISTRIer <br /> ' <br /> ATM [NLIE RGRO M TAW PROM.9i{ <br /> P. D. BOX 2009 <br /> STOCK701, CA 95202 <br />