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� t <br /> • I <br /> SAN JVe(ZtIIN COWIT PUi1LIC 11EAi,T11 SF_RVIA-7ES ' <br /> w RONMEN'1'Af. HRALTII DIVISION <br /> UNDERGROUND SMR AGE TANK DiSPOSMON TRACKING RECORD <br /> a.rarrra}iifaar+♦fiiiiaar+♦salsa+++«iaiii+♦++♦♦aiiaaawa«fawwiwaaaw##44*«*44♦«44!44#44444!1444!444!444444444 <br /> .^,F t'i it1 ) 1 1'1111ilr. ilraUlr .Setvicet Rnvirrtrnnr111M liralth Divitirm•T-ank Tracking .Sheet 1hall accompany each Iwnk affixed <br /> ,.Orh iri iitr irlrnilrlradon nnnn11rr. the "Tank T'rarkinR Shcet it ro be rennned to Pmbtic llealth Services Frivironmentai Health <br /> Itiviai.rn tiriUtln 30 dnvs of arr.rponre of the Iank by the disposal or recycling facility. The permit holder Is responsible for <br /> rnsnring 11111 this form It completed and trinrned. <br /> l'A(:11.11'Y NAiiir?: Van De Pol Enterprises 1,.1�.A, p CAC002102104 <br /> I•A(:ll.lIY ADORrS;: 3230 N. West Lane, Stockton , CA 95204 <br /> TANY� 11.) #39 � ; _ b TANK sum: 10,000 900-vivUS -TANK CONTENTS: Diesel Fuel <br /> leers}raffia+aria}+++#i+i+#Mf«+ii#ffiiffifafiiffwwM#«i##w#«if#f#♦f#f♦##44##♦♦��il14444!!!4!+*!!!4!!!!!!!!!! <br /> Sr,.(;i IM4 I - To be filled om by lank removal contractor: lJ <br /> link Rrrnovai Oinitactor._ Jim Tborve Oil, Itis. <br /> Arbhrss: . 35!- N.,.. LTecluna►r_lid./1'.0. Box 351 —� _ City: Lodl, CA Zip: 95241-0357 <br /> Ninth 1: ( 209 _) J68-6175 Date Tank Removed: <br /> .••a.aa..aaiai+ai+air++ii♦iataaaialaaaiaiiai«a+«ai«««««warwawawaww4ww4#«##««44444 .!4144#4!4!44!!444!4!4!!44 <br /> SR(:'iloN 3 - 'To he filled not by contractor "decontaminating tank": <br /> lank hr:rnntnrninatfon Contractor: JIM '1hOt- le Uil, Irtc. <br /> Arifir.tt: 351 11, Beckin,' r [1d./P.O. Box 357 (sty: Lodi., CA 71p:95241-0357 <br /> 1'hnnr l: ( 209 ) 368-6 1*15 <br /> Aurhrni7rd irprrsrntative of contractor certifying thrmigh signature below that the lank has been decontaminated in an approved <br /> nllnnrr at rcrinirr-d by Of ITA. <br />[tarnc: _ ___—_ fide: Signature: bete <br /> a ,}+ ..ala «♦«ii# ♦ai ♦ ♦« 4wfaaf# i «+ «4a«## w♦«ww##«w##wia«##«« 4 4*144♦ !4 On! 444!4#an�C i s f ree of a t� 1uyeai ,V(1j,ogArbon vapors i1�1on cle��vet �o � ��5i (;1 iON 4 - 1'o be ifgned and elated by an sot for re represents ive of t e treatment. Ito ag , orpos ac i t <br /> icceptfivg tank and/or piping. <br />'lr iilry llnrnr.: Scltrti.l.zet "I eel Prodixt.s <br /> if;trlcho Cordova, CA <br /> Irlrltcs.r_ --IZ000 ['ols(�tn HIM. City: Zip., 95742 <br /> 916 ) 985-48I0 <br />'nte Tank ticcrNed: <br /> Signature: Date <br />•ra+iaiiii+ii++iaii++«a+ii««+f+iwi#f#«sail+aaf«air#4N1w«iiwwi+a««4a#«##44444444�4l444444444l4l444l4444 <br /> 1 23 0-16 (Revised 9/11/96) page 10 <br /> i <br />