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S.?'!►N '7aAQTN LOCAL k4F_, rH SWTR:IC'r <br /> UNDERGROIAlD TAW DISPOSITION TRJaiNa psooRp <br /> f1A1'f!1`*R1*lMlx#R!#xi#f!'R#!7t##ttxx!#xRtxi*#itxxx!llxitxx#*!xxllxatx#RA!!!tR#�tiA'#!##lRxiM#R#R11�� <br /> ._ION 1 - The San Joaquin Local Health District's Tracking Sheet will aecampapy 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 /> rOOCYCling facility. <br /> lna ,t,It this farm is comnletCd.and ret„r^C <br /> `MULITY VAMC: Puregro Comganv <br /> 1WILITY ADDRESS: 1904 W. Charter Way, Stockton, CA <br /> TJ* Tp 839- EPA Site #CAD 009109844 <br /> 1 - 1 ,000 gallon unleaded gas tank <br /> �►.�!'!'�IRR###!#xx#1txxx#x#x*#Rxxft*x#xlxxxxxx�xxxxxx+rx�feye#�xxxxx#u#ft#xsx�!*xs!!1t#!iR#sslxisslR <br /> MMOK - 2 - To be f i l led out by tank removal contractor: r <br /> • '7i nk Removal Contractor: J IM T f OR P E OIL, INC. <br /> : Addxeaa: 351 N. Beckman Road, Lodi , CA 95240 <br /> Phone#Zip <br /> << 6�8 61 <br /> Tielephone: { ) Date Tank Removed: _2;z4//!?d <br /> !1'=R�RSR#!!xx#xxxxx*###1xxx#xx�xxxtFlrx�R*fkx�►itxx#xxxlsxltxxRi#IR�tR#R#1ts*ts##lit*!xx!!s!t#!R*!ss#R <br /> `- '!'ION 3 -To be filled out by contractor "decontaminating tank": <br /> Decontamination" Contractor. <br /> JIM THORPE OIL,. INC. / Nor-Cal Oil * Hauler of rinsate <br /> } 351 N. Beckman Road, Lodi, CA <br /> Zip. 9524) <br /> a. .: <br /> r <br /> Phone#: (209) 368-6175 <br />. uthorised representative of contractor certifies by signing below that the tank has been <br />; ontawihated in an approved manner as may be regulated by Department of Health Services. <br /> y <br /> Vice-President <br /> STGNIATURE ITLE <br /> .si�i!#!#1�tx#xxxxxxxxxxx#xxxxxxxxxxxxxxxxx*x*xxxxxxxxx**xxxx*l�xxxxxxxxxRxxs:xxxxx�xxxxxxxxx <br /> WSW <br /> 'ICU 4 - To be filled out and signed by an authorized represnetative of the treatment, <br /> storms, or disposal facility accepting tank. <br /> Name fTZER STEEL PRODUCTS CO <br /> SCHN <br /> ]� 12pp0 FOLSOM BLVD�57G2 <br /> RANUHU <br /> Zip: <br /> Phone#: <br /> Cote TaMk Received: <br /> Wnwm"W SIGNATUO AND TITLE <br />"x '23 Dt9 2?/8t <br /> Iii"U rNSTRUCPIONS: FCC IN HALF AND STAPLE. AF'F'IX PROPER "rA(Z. <br /> SAN JOAWIN LOCAL HEALTH DISTRICT <br /> " AM: UNDER(kl.1ND TAW PROOR M <br /> P. 0. BOX 2009 <br /> a sr ; �• <br /> a t <br /> ST�0(.XTON, <br /> CA 95202 <br /> tk <br />