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SITE INFORMATION AND CORRESPONDENCE
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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JACK TONE
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13475
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3500 - Local Oversight Program
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PR0545314
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SITE INFORMATION AND CORRESPONDENCE
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Last modified
2/11/2020 10:29:58 PM
Creation date
2/11/2020 9:42:01 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0545314
PE
3528
FACILITY_ID
FA0005333
FACILITY_NAME
JACKPOT
STREET_NUMBER
13475
Direction
N
STREET_NAME
JACK TONE
STREET_TYPE
RD
City
LODI
Zip
95240
APN
06326004
CURRENT_STATUS
02
SITE_LOCATION
13475 N JACK TONE RD
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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i <br /> SECTION E: ASBESTOS + <br /> i <br /> Indicate containment for asbestos: <br /> ❑ bags ❑ cartons ❑ drums ❑ wrapping <br /> ❑ other <br /> NOTE: Al asbestos must be prepared for transportation to and disposal at the <br /> Forward Landfill in accordance with all applicable regulatory requirements. <br /> SECTION F: SHIPPING INFORMATION <br /> Method: ❑ Bulk Liquid 9 Bulk solid <br /> ❑ Containerized (type): <br /> Quantity: 50 0 Cubic yards ❑.gallons <br /> i <br /> per ❑ month D year 0 one time only <br /> ❑ other <br /> NOTE: All shipments must be approved by the Forward, Inc. Environmental <br /> Compliance Officer or Solid waste Coordinator prior to delivery. <br /> i <br /> SECTION G: CERTIFICATION/INDEMNIFICATION STATEMENT <br /> The below-named company warrants that the above and any attached or submitted <br /> waste characterization is complete and accurate and that based upon testing and I <br /> analysis performed on the waste materials, none of the waste materials are <br /> hazardous as defined by 40 CFR, Part 261, and the California Code of Regulations, I <br /> Title 22. with the exception of asbestos which is properly described in sections <br /> E and F above. In the event that any portion of the waste materials (other than <br /> asbestos properly described in sections E and F above) is determined to be <br /> hazardous ("Hazardous Materials") according to any of the above mentioned <br /> regulations, each party shall notify the other in writing immediately upon <br /> learning of such determination. The below--named company shall within ten (10) <br /> days after receiving such written notification regarding a hazardous <br /> determination, and at the below-named company's sole expense, from the Forward <br /> Landfill and properly dispose of them elsewhere. The below-named company <br /> warrants that any asbestos delivered to the Forward Landfill has been properly <br /> described in sections E and F above and has been prepared for transportation to <br /> and disposal at the Forward Landfill in', full compliance, with applicable <br /> regulatory requirements. <br /> The below-named company shall defend, indemnify and save harmless Forward, Inc. , <br /> its affiliates, their officers, directors, agents, representatives and employees <br /> and their successors and assigns from any liability, claims, losses, damages, <br /> costs, liens, judgments, orders, government directives, or expenses of any kind <br /> in connection with the hazardous materials -and/or non-conforming waste and in <br /> connection with any breach of the below-named company's warranties given or the <br /> below-named company's obligations undertaken- herein.. <br /> The below-named company agrees that, in the event that it learns that the waste <br /> constituents vary from those set forth. above or on any attached or submitted <br /> documents, it will immediately submit a corrected waste characterization form. <br /> COMPANY: Time Oil <br /> i <br /> BY: (Print Name) _ c`�-12,Fc OL- TITLE: y - PC <br /> S I GNATURE: DATE-.' 112619 "Z <br /> i <br />
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